Singapore, 13 May 2023 - Family doctors will feature prominently in Singapore’s new healthcare reform plan, Healthier SG. To prepare them to take on the expanded responsibilities including social prescribing, Care Corner Singapore and the various community partners in Toa Payoh, together with Tan Tock Seng Hospital (TTSH), are actively inducting family doctors in Toa Payoh into their Communities of Care (CoCs). The first such induction took place this afternoon, as part of TTSH’s Continuing Medical Education (CME) for doctors, at Care Corner’s Active Ageing Centre at Lorong 4 Toa Payoh.
TTSH shared up-to-date information on care management of health conditions, while Care Corner highlighted their one-stop social support for family doctors and the different social programmes that they can refer Toa Payoh residents to. This co-organised CME is the first community-helmed CME that explores collective care for seniors. The session helped to inform family doctors of the neighbourhood-based network of health and social care partners who are ready to support them in walking with residents to good health. TTSH will be working with partners in their other CoCs to carry out similar CMEs for family doctors in their neighbourhoods.
Toa Payoh’s Communities of Care
The CoC is an overarching framework commissioned by the Agency for Integrated Care (AIC) to build local networks of care, bringing community care partners, family doctors, and health and social care agencies together to work closely on the health and social needs of residents in the neighbourhood. Several CoCs in Toa Payoh are anchored by Care Corner, with strong support from TTSH, and includes members such as National Healthcare Group Polyclinics and AIC. Toa Payoh is one of the oldest neighbourhoods in Singapore where more than a fifth of the residents are above 65 years old. Almost one in three of the elderly residents lives alone. There is hence a pressing need by Care Corner’s CoC to ensure that these residents are better supported to lead healthier lives.
Stronger Together, a programme featured in the CME, was co-developed by Care Corner and TTSH to address frailty issues in seniors through a holistic model of nutrition education, chronic disease management, customised exercise regime and psychosocial support. The family doctors got to understand the programme and in time to come can screen and prescribe Stronger Together as an intervention for Care Corner to help senior residents strengthen their bodies and minimise the risk of succumbing to complications of falls.
Care Corner would also be working closer with family doctors to identify cases of neglect, abuse, social isolation and mental health concerns in the neighbourhood that may otherwise go unnoticed. Family doctors can refer seniors to Care Corner's Active Ageing Centres in Toa Payoh for monitoring their vital signs, and connecting them to home care services (e.g. nursing care such as wound dressing or medication management). The centres also provide opportunities for seniors to build social connections, participate in recreational activities, and contribute to the community through volunteering. Refer to Annex 1 for the resource guide to family doctors.
Through this social-health partnership, we hope that residents can better access the wide range of social care services in the community and that care will be rendered in a timely and coordinated manner. This allows us, together with the residents, to co-create conditions that support healthy ageing and promote physical, mental, social, and emotional well-being."
- Joe Tan, Manager at Care Corner Singapore
Another area that the CoCs would be looking at is the
management of post-discharge complex care patients in the community. The aim is for appropriate care interventions and referral decisions to be made collectively by TTSH’s Community Care Teams with the CoCs, to better support these discharged patients for their specific health and social care needs. Family doctors are set to join case consultations, and become an integral part of the CoCs to provide care closer to the residents.
With an ageing population, frailty, social isolation and disabilities become key social determinants for health. These cannot be managed by a medical model alone. The CoCs we collectively build adopt a lifecourse approach where health and social care are integrated to focus on preventive care and healthier living. Through the CMEs with CoC partners, we can better support our family doctors in their development of health plans for our residents to access earlier care interventions and empower them to lead healthier lives."
- Adjunct Asst Professor Jerome Goh, Clinical Director, Division for Central Health, TTSH
TTSH is currently piloting an e-referral system for family doctors in Central Singapore to make referrals to TTSH’s specialists more efficiently, track the progress of the referral, and receive an update from the hospital’s specialists on the patients’ conditions. This will facilitate continuity of information and care in the residents’ subsequent visits with their family doctors. The system will also guide family doctors through social prescribing, prompting them on potential programmes and activities based on their assessment of residents’ conditions and interests.
I think it is a good initiative by TTSH and community partners like Care Corner to proactively engage family doctors in providing greater holistic care for elderly patients. Our population is ageing and together with the Healthier SG initiative, I think it will help to address the areas which are lacking in our current healthcare system."
- Dr Kevin Loy, Family Physician, Doctors Inc Medical Group