Building a Healthier Community through our Community-of-Care

Eighty percent of primary care in Singapore is provided by about 1,800 General Practitioners’ (GP) private clinics, with polyclinics caring for the rest. As of July, primary care doctors have become the navigators to the health journey of our residents. Singaporeans and Permanent Residents from the age of 60 have begun their enrolment into Healthier SG with one of these clinics of their choice. Other residents will be invited to sign up progressively, starting with those aged 40 to 59.

Tan Tock Seng Hospital (TTSH) & Central Health has a strong part to play in in the GPs’ expanded role. We will strengthen our support for our GP partners in the Central zone by wrapping around care and support for our residents in the communities where they live. Working with our community partners and agencies like Health Promotion Board and Agency for Integrated Care, we hope to better integrate health and social care programmes.

Facilitating Social Prescribing in Jalan Kayu

As regional health manager for the Jalan Kayu constituency, our Community Health Teams (CHT) participated in the Healthier SG pilot rolled out in that neighbourhood. Our role in the collaboration was to identify workflows and establish care link-ups between the participating GPs and community partners. Residents who have developed their health plan with their enrolled GPs could directly access social and community programmes within their neighbourhood. Within the Jalan Kayu CoC, our community partners includes Health Promotion Board, People’s Association, Sports SG and Active Ageing Centres such as Home Nursing Foundation, would support resident’s health plan by providing a wide variety of social and community programmes.​

For residents that required closer social support or have complex needs, our CHTs supported the social prescribing needs of such residents who are referred to them by GPs. Lastly, TTSH & Central Health’s GP relationship managers served as the single point of contact to support the family doctors in their referral pathway for social prescription and tertiary care.

GPs roped into Community of Care at Ang Mo Kio to better support residents with Preventive Screening

To support residents in Ang Mo Kio to lead a healthier and happier life, a CoC network made up of the six partners – AWWA, Health Promotion Board (HPB), PanCare Medical, Silver Generation Office (SGO), TTSH and Yio Chu Kang Grassroots Organisation – organised ‘Health Fiesta: Meet a Healthier You!’ in March 2023. Health Fiesta is a community-led initiative to bring preventive screenings to Ang Mo Kio residents.

Over the two days of public outreach, the community saw multiple key stakeholders and our volunteers collaborate in multiple areas:

• AWWA, SGO and Yio Chu Kang Grassroot Organisation conducted the initial outreach to residents, encouraging them to sign up for health screening
• AWWA provided dementia screening
• TTSH and HPB provided fall risk and function screening
• PanCare Medical Clinic provided vaccination and chronic disease screening

Post-Health Fiesta, PanCare Medical Clinic provided health counselling to all participants on how to keep themselves healthy. AWWA and Yio Chu Kang Grassroots Organisation further complemented these efforts by rallying the interest groups to introduce their activities that residents may participate in to stay active and healthy.

With an ageing population and increasing healthcare demand, we must shift our focus from reactive care to proactive care. This is the essence of Healthier SG and now part of our mission to care for the population we serve and not just those who come to our hospital. At the forefront of delivering such proactive care is our trusted GP whose relationship with the resident will be strengthened and supported with Healthier SG.