Building Local Networks and Communities of Care (CoC)

The pandemic has disrupted the way we all work and deliver care in the community. Many of us have developed our own strategies to adapt to the new norms. This pandemic has highlighted the urgency to develop local networks to ensure that care will not be disrupted regardless of the challenges.

Community of Care (CoC) is an overarching framework commissioned by the Agency for Integrated Care (AIC) to build local networks of collaboration among providers, and to deliver holistic health and social care for residents in their neighbourhood. It places the resident in the centre of our community care ecosystem so that better support could be provided to help them age in place.

Within the CoC, the dedicated network of partners work together to provide holistic services for the residents.  This network could potentially comprise of the following key stakeholders contributing to the resident's longitudinal care plan:

1. Anchor partner who drives and coordinates collaborative efforts to ensure the overall well-being of the residents;
2. CHTs from the Hospital who work alongside the anchor partner and provide health and lifestyle interventions;
3. Primary care provider who anchor the clinical management;
4. Community partners who provide additional services that residents require beyond what the Anchor Partners and CHTs offer; and
5. Empowered residents or PSL who motivate and lead their own peers to continue engaging in self-directed activities and to spread health behaviours

A successful CoC will allow for residents to age in place within their neighbourhoods, feel supported and maintain a high level of participation  in the management of their own health.

With the aim to gather and build upon valuable insights on CoC from various providers, multiple Central Health partners came together at Central Health Action & Learning Kampung (CHALK) 2020, held on 11 December 2020 to discuss how this new way of partnering could be embedded into the new normal of care delivery.

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Our distinguished panellists from TTSH, AIC, AMKFSC, Care Corner and a General Physician, shared their perspectives on the strategies for building an ideal CoC. They highlighted the need for a localised approach as the profile of residents varies between neighbourhoods, and discussed how hospitals can support continuity of care transitions, data sharing and capability building. Most importantly, the partners emphasised the importance to have a common agenda and shared goals, as well as support from residents, volunteers and Primary Care. Their perspectives have been amalgamated into a single diagram below.

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This is our vision of success if you are asking us. We are focusing on the seniors at the centre of what we do. The local CoC should be able to support the seniors and their family members and caregivers to live the way they wanted, which is aging in place and be at home.”

– Mr Tan Kwang Cheak, Chief Executive Officer, Agency for Integrated Care

I see the hospital projecting itself, its resources and services out into the community because if you think about it, the hospital is also part of the community. We should also be contributing in areas such as data sharing and capability building as part this community.”

– Adj A/Prof Ian Leong, ACMB, Community Care Integration, Tan Tock Seng Hospital

I thought of 3 keywords; knowing where they are as we need the eyes and ears on the ground. From the knowing, we will need to encourage more of our community members, whether they are willing to be involved. Finally, how do we then empower them to start acting.”

– Mr Daniel Chien, Senior Group Director, Seniors Services, Care Corner Singapore

When we see areas with elderly hanging around, we will go to those places to conduct structured activities. The elderly will get curious on the activities and they will happily gather rain or shine. Overtime, with word of mouth, you can easily garner a community of around 50 residents.’

– Mr Ng Koon Sing, Senior Assistant Director (Community Care), AMKFSC Community Services

We GPs are default second line for the local elders to go to. Probably because we are the nearest to them, familiar with them and open after office hours. While a lot of these elderly come to us for medical issues, there are coupled with psycho-social issues such as depression and anxiety. So I think GPs need to be further supported and work with community partners to address the aforementioned.

– Dr Eng Soo Kiang, General Physician and Clinical Lead of NHG Central-North Primary Care Network