03CHAPTER THE THREE ZONES - National Healthcare Group

Page created by Erik Hammond
03CHAPTER THE THREE ZONES - National Healthcare Group

                                   THE THREE ZONES
                                   In January 2017, the six clusters in the Singapore public
                                   healthcare system were reorganised into three clusters
                                   to cover the Central, Eastern, and Western geographical
                                   regions. For the National Healthcare Group (NHG), it
                                   led to the amalgamation with Alexandra Health System
                                   (AHS) in October 2017 to manage the care needs of
                                   the Central Region in Singapore.

19   © National Healthcare Group                                                               © National Healthcare Group   20
03CHAPTER THE THREE ZONES - National Healthcare Group
                                                    Healthcare                                                   BEYOND HOSPITAL TO COMMUNITY
                                                      (NHG)                                                      To fulfil its mission as the anchor hospital of the Integrated   with the community – which includes Primary Care
                                                                                                                 Care Organisation (ICO) for Central Zone, which involves         providers, Community Care providers, and Voluntary
                                                                                                                 fostering care integration and encouraging value-based           Welfare Organisations (VWOs) – to form an Integrated
                                                       CENTRAL                                                   care, TTSH launched the Division for Central Health (DCH)        Care Network that builds capabilities, co-develops
                                                                             EAST     Singapore                  in September 2017. DCH serves a population of about 1.4          integrated care programmes, improves the accessibility
                  National                                                              Health                   million people, the largest population catchment in the          and convenience of care, and activates the whole zone
                 University                                                            Services                  country, as well as the oldest with 17 per cent of residents     for greater ownership of health.
                   Health                                                               (SHS)                    aged over 65 years, a higher proportion than the national
                  System                                                                                         number (13 per cent). A significant slice of our elderly
                  (NUHS)                                                                                         population, about one in three, is Frail. This translates to
                                                                                                                 a high demand for healthcare services, and requires DCH
                                                                         “THE TRANSFORMATION                     to go beyond providing illness care within our hospital
                                                                                                                 and clinics to integrating health and social services in
                                                                         OF SINGAPORE’S PUBLIC                   the community, thereby meeting the population’s rising
                                                                         HEALTHCARE LANDSCAPE IS NO              complex care needs.

                                                                         SMALL FEAT, AND WE CANNOT               Central Health’s concept and delivery of care has
                                                                                                                 progressively shifted from episodic, facility-centric, and
          In Singapore, age adjusted per capita bed days in acute        DO IT ALONE. WE NEED TO BUILD           volume-driven to relationship-based, person-centred,
          hospitals have steadily risen since 2006, driven mainly
          by an increase in admissions. This upward trend can be         BRIDGES TO STRENGTHEN TRUST             and value-driven. It is working in closer partnership
          attributed to our ageing population and the first wave         AND RELATIONSHIPS WITH OUR
          of Frailty, which has been well documented as a leading
          cause of healthcare utilisation. To bend this demand curve     PARTNERS IN THE COMMUNITY SO            THE CENTRAL HEALTH MODEL OF CARE
          and maintain our population well in the community, NHG         THAT WE CAN KEEP HEALTHCARE
          collaborates with an alliance of providers in the Central                                              Central Health aims to strengthen the physical, mental, and social wellness of our patients and population. To enhance
          Region. As an Accountable Care Organisation (ACO),             SUSTAINABLE AND IMPROVE THE             the value of care delivered and improve the health of the community, Central Health is shifting towards healthcare
          we aim to meet the care needs of a population of two           HEALTH OF OUR POPULATION.”              delivery that is:
          million in an effective and efficient way. This has involved
          regionalisation of the NHG Cluster into three ‘operating’      PROFESSOR PHILIP CHOO, GROUP CEO, NHG   • Joined-up through a network of care providers
          zones – Central Zone, Yishun Zone, and Woodlands Zone
                                                                                                                 • Needs-based through a thorough understanding of the local needs of our community
          – led by the three Integrated Care Organisations (ICOs):
                                                                                                                 • Neighbourhood-based to make care easily accessible in the community
          • Central Health                                                                     Yishun
                                                                                                Zone             • Relationship-based by creating a Community of Carers supported by Community Health Teams
          • Yishun Health

          • Woodlands Health

          The three ICOs are helmed by their respective anchor                                                     TODAY                                    TOMORROW
          hospitals – Tan Tock Seng Hospital (TTSH), Khoo Teck
          Puat Hospital (KTPH), and Woodlands Health Campus                                                                                                 Joined-Up Care
          (WHC) – which collectively serve to provide care in
                                                                                                                   Fragmented Care                          through a Network of
                                                                         Woodlands                                                                          Care Providers
          collaboration with internal and external partners in their       Zone
          locality to meet their distinct sub-populations’ health and
          social needs. This system of place-based care enhances                                     Central                                                Needs-Based Care
          accessibility and convenience for the population, and                                       Zone         Disease-Based Care                       by understanding the local
                                                                                                                                                            needs of our community
          enables the formation of trust-based relationships that
          ultimately result in better health outcomes.
                                                                                                                                                            Neighbourhood-Based Care
                                                                                                                   Facility-Based Care                      where care is proximal to our

                                                                                                                                                            Relationship-Based Care
                                                                                                                   Episode-Based Care                       where a Community of Carers is supported
                                                                                                                                                            by Community Health Teams

                                                                                                                 Figure 1: A Desirable Shift towards Value-Driven Care

21   © National Healthcare Group                                                                                                                                                                                        © National Healthcare Group   22
03CHAPTER THE THREE ZONES - National Healthcare Group
The Central Health model of care encompasses the following six key strategies:
                                                                                                                                                ONE COMMUNITY OF CARERS
          • One Community of Carers to activate individuals to                • One Population, One Budget to align funding,                    Central Health is working to activate patients, caregivers, and volunteers by equipping them with the knowledge,
            take care of themselves, their family, and others in the            incentives, and subsidies to make care more accessible          skills, and confidence to assume their critical role in managing health and well-being in the community. This involves
            community                                                                                                                           experiential learning and encouraging small behavioural changes as the primary modes of activation, and goes beyond
                                                                              • One Menu of Programmes to co-create programmes                  illness management and treatment adherence to include wellness and prevention. Some key initiatives for building one
          • One Network of Providers to bring health and social                 and facilitate integrated care planning and pathways            Community of Carers include:
            care partners together, thereby strengthening the                   for seamless care
                                                                                                                                                • CareConnect
            health of our community
                                                                              • One Set of Assessment Tools to establish a common
                                                                                                                                                • Singapore Patient Conference (SPC)
          • One Community Health Team to create dedicated                       language across providers and understand the needs
            inter-disciplinary health teams with our partners to                of our community                                                • Centre for Health Activation
            provide better care in each neighbourhood

                                                                                                                                                CareConnect is TTSH’s dedicated patient experience centre. It serves as a one-stop
                                                                                                                                                information hub for patients and caregivers, providing them with access to resources within
                                                                                                                                                and beyond the hospital. These resources include educational materials, talks, training
                                                          CARE                                                                                  programmes for patients and caregivers, and volunteer-led activities. CareConnect also
                    Our                                                                                                                         gathers useful patient feedback that contributes to continuous improvement of care.


                                                                                                                                 BASED CARE
                                                                                ONE COMMUNITY                                                   Singapore Patient Conference (SPC)
            are focused                                                           OF CARERS
                                                                                 Activation and
                                                                                                                                                The Singapore Patient Conference (SPC) brings together patients, caregivers, volunteers,
           on Activating                                                          Ownership of
                                                                                                                                                community partners, and healthcare professionals annually to share new ideas that
                                                                                                          ONE COMMUNITY
                                                                                                           HEALTH TEAM                          promote the co-creation of a better healthcare ecosystem.
                    Our                                                                                   Inter-Professional
                                                            ONE NETWORK
               Community                                    OF PROVIDERS
                                                            Integrated Care
                                                                                                                                                Centre for Health Activation (CHA)
                                                                                                                                                The Centre for Health Activation (CHA) was launched in October 2017 to drive activation
                                                                                                                                                and build capabilities in patients, families, volunteers, and the community. The three

                                                                                                                                                pillars of CHA are:
                                                                                     OUR Residents
                                        BASED CARE

                                                                                                               ONE MENU OF
                                                                                                               Meeting Health
                                                              ONE POPULATION,                                    and Social
                                                                ONE BUDGET                                         Needs                            1. Activation
                                                                Alignment of
                                                                 Incentives/                                                                            CHA provides patients, caregivers, and volunteers with resources to make
                                                                                                                                                        effective decisions about their own health and well-being, as well as the
                                                                                        ONE SET OF
                                                                                     ASSESSMENT TOOLS                                                   opportunity to become healthcare volunteers. This enables them to serve as
                                                                                      Understanding the
                                                                                        Needs of our              NEEDS-BASED                           a bridge that provides continued support for patients who are discharged
                                                                                         Community                   CARE                               from the hospital into the community.

                                                                                                                                                    2. Research
                                   Figure 2: The Central Health Model of Care – Four Principles and Six Strategies                                      CHA collects feedback from patients, families, volunteers, and healthcare
                                                                                                                                                        professionals to identify the needs within the community and develop
                                                                                                                                                        better programmes and training. Going forward, CHA also aims to work
          The Central Health Model is being operationalised within seven sub-zones (namely, Ang Mo Kio, Bishan, Geylang,                                with external academics and researchers on socio-behavioural research,
          Hougang, Novena-Kallang-Rochor, Serangoon and Toa Payoh) through six care streams that address the needs of our                               and to leverage on established patient activation management tools with
          patients across the River of Life:                                                                                                            international benchmarks.

          • Preventive Care                                                                                                                         3. Training
                                                                                                                                                        CHA upskills volunteers through personalised training programmes created
          • Primary Care
                                                                                                                                                        by TTSH, and also leverages on training resources offered by our community
          • Hospital Care                                                                                                                               partners, particularly for caregiver-training and befriending. There are three
                                                                                                                                                        levels in the Training Roadmap.
          • Intermediate Care

          • Transitional and Community Care

          • End-of-Life and Long-Term Care

23   © National Healthcare Group                                                                                                                                                                                                                     © National Healthcare Group   24
03CHAPTER THE THREE ZONES - National Healthcare Group
Level                                                           Level

               1                                                             2                                                           ONE NETWORK OF PROVIDERS
          All volunteers undergo basic induction, training, and           After being assessed as competent in core skills, volunteers   Engagement of community partners for patient referrals          Service Provision
          assessment in core skills before taking on specialised skills   are matched to specialised skills training programmes          and case management is not new but our relationship
          and programmes. There are three programmes, namely,             according to their interests, competencies, and skills.                                                                        DCH works with our internal and external partners in
                                                                                                                                         with health service providers in the community has largely
          Increasing Physical Activity and Enhancing Mobility,            Most of our existing TTSH volunteers are at this level of                                                                      the community to serve and coordinate care for the
                                                                                                                                         been transactional in nature, with patients being referred
          Fostering Positive Medication Habits, and Promoting             training, and signature programmes include the Temasek                                                                         population across the eight domains, thereby optimising
                                                                                                                                         to them post-discharge for follow-up care. To actualise
          Good Practices in Chronic Disease Management. These             Foundation Cares-CHAMPS programme and the Inpatient                                                                            manpower and reducing duplication of efforts. Some of
                                                                                                                                         the shift to the Central Health Model, there is a need for a
          programmes are also extended to our community                   Total Knee Replacement (TKR) Volunteer Programme.                                                                              the services include:
                                                                                                                                         local network of health and social care partners to come
          partners, and customised according to the particular                                                                           together to strengthen the health of our community in a         •   Case Management and Care Coordination in the
          needs in each community.                                                                                                       holistic and concerted manner.                                      Community
                                                                                                                                         At the macro level, Central Health is working to achieve        •   Home help services, medical escort and transport
                                                                                                                                         this by co-creating a common vision with shared goals               services
                                                                                                                                         that will guide collaborations among service providers.
                                                                                                                                                                                                         •   Dementia care and mental health services
                                                                                                                                         The key is to build a strong network of like-minded
                                                                                                                                         partners to deliver integrated and comprehensive care in        •   Primary Care services, home medical care services
                                                                                                                                         the community to improve population health outcomes.
                                                                                                                                                                                                         •   Home nursing services, centre-based nursing services
                                                                                                                                         To effect this change, a tiered approach is adopted:
                                                                                                                                                                                                         •   Community-based rehabilitation services,
                                                                                                                                         • For providers that are (i) better aligned with the
                                                                                                                                                                                                             intermediate rehabilitation services
                                                                                                                                           Central Health mission, (ii) already have an existing
                                                                                                                                           working relationship with TTSH, and (iii) have expressed      •   Health screening, health coaching, counselling
                                                                                                                                           readiness to collaborate on relevant projects, their
                                                                                                                                                                                                         •   Hospice services, home palliative care
                                                                                                                                           inclusion into the Network of Providers as a ‘Strategic
                                                                                                                                           Partner’ is formalised through a Memorandum of
                                                                                                                                           Understanding (MOU). The MOU signifies the intent
                                                                                                                                           to collaborate with TTSH and other providers in the
                                                                                                                                           Central Zone in areas including (but not limited to)          We engage our partners closely, and continually identify
                                                                                                                                           development and implementation of integrated care             and work on opportunities for the improvement of care
                                                                                                                                           and training programmes, sharing of population data           integration to ensure seamless and smooth transition of
                                                                                                                                           where appropriate, community engagement, as well as           patients from hospital to home. This includes identifying
                                                                                                                                           co-learning, and innovation.                                  and addressing service gaps in the community ecosystem,
                                                                                                                                                                                                         establishing co-management and case management
                                                                                                                                         • With other providers, i.e. our Community Partners,
                                                                                                                                                                                                         workflows, and data-sharing for care continuity.
                                                                                                                                           DCH continues to engage at the neighbourhood level,
                                                                                                                                           collaborating with them on relevant projects aimed at
                                                                                                                                           meeting the specific health and social needs of the local     Activation
                                                                                                                                           community.                                                    Central Health aims to empower the community so that
                                                                                                                                                                                                         residents have access to quality care closer to where
                                                                                                                                         The relationships with the Strategic and Community              they live. This involves co-learning and co-sharing of
                                                                                                                                         partners are fostered and maintained through efforts            best practices, and the co-creation of programmes that
                                                                                                                                         including regular leadership dialogues, “Neighborhood           promote integration of care. We actively engage anchor
                                                                                                                                         Conversations”, and the annual Central Health Action and        partners who are well established in the Central Zone as
                                                                                                                                         Learning Kampung (CHALK) event.                                 part of our community planning to oversee and chart plans
                                                                                                                                                                                                         for the co-development of initiatives aimed at achieving
                                                                                                                                         At the micro level, the creation of this Network of Providers
                                                                                                                                                                                                         the overall well-being of our population. Thus far, Central
                                                                                                                                         aims to meet the needs and improve the quality of
                                                                                                                                                                                                         Health has on-going internal partnerships with members
                                                                                                                                         care for our population based on eight domains of the
                                                                                                                                                                                                         of the NHG Family, such as National Healthcare Group
                                                                                                                                         community health ecosystem: Case Management and Care
                                                                                                                                                                                                         Polyclinics (NHGP), Institute of Mental Health (IMH), and
                                                      Figure 3: CHA Training Roadmap                                                     Coordination, Personal Care, Mental Health Care, Medical
                                                                                                                                                                                                         National Skin Centre (NSC), and external partnerships
            Level                                                                                                                        Care, Nursing Care, Function, Preventive Care, and End-
                                                                                                                                                                                                         with Ren Ci Hospital, Kwong Wai Shiu Hospital, and Tsao

                                                                                                                                         of-Life Care. This holistic approach to care is driven by
                                                                                                                                                                                                         Foundation, among others.
                                                                                                                                         a three-pronged engagement plan – Service Provision,
                                                                                                                                         Collaboration, and Activation.

          Volunteers with a passion for community outreach are
          deployed to support the Community Health Teams based
          in each of the seven sub-zones, and are matched according
          to the needs of the community and geographical proximity.

25   © National Healthcare Group                                                                                                                                                                                                                  © National Healthcare Group   26
03CHAPTER THE THREE ZONES - National Healthcare Group
          ONE COMMUNITY                                                 ONE POPULATION,
          HEALTH TEAM                                                   ONE BUDGET                                                     Central Health leverages on the strengths and offerings of all providers in the Central Zone to support the needs of
                                                                                                                                       our population. The One Menu of Programmes is a directory of programmes run by various partners in the community
                                                                                                                                       that helps the placed-based CHTs identify suitable community and/or clinical programmes to refer patients to, based
          Central Health hopes to eventually establish One              To better incentivise multiple care providers to collaborate   on needs and geographical proximity. The Menu also references the principles of the Five Bliss – Longevity and Healthy
          Community Health Team (CHT) composed of members               as an alliance to holistically support patients along the      Living, Financial Management, Peace of Mind, Contribution, and End of Life.
          from both TTSH and our community partners in each of the      entire care continuum, NHG aims to establish a Population-
          seven sub-zones. We have begun this process by forming        Based Capitation Model that enables effective coordination
                                                                                                                                       Figure 4: Principles of Five Bliss
          multidisciplinary CHTs, which include TTSH doctors, nurses,   across the spectrum of care, optimises utilisation of
          Allied Health Professionals (AHPs), and pharmacists, to       resources, and minimises waste (for more information,
                                                                                                                                                                                          Longevity & Healthy Living
          build long-term relationships with our population and our     see p.97). In preparation for this eventual shift, Central
                                                                                                                                                                                          Function, Nutrition, Cognition,
          community partners across the healthcare and social care      Health is working on several pilot schemes to test new
                                                                                                                                                                                          Management of Health Conditions
          sectors. Collectively, the One Community Health Team          funding models that enable value-based care and right-
          within each sub-zone will meet the unique needs of the        siting. One such model is bundled payments of Diagnosis-                                                          Financial Management
          population based on each zone’s profile, and enable health    Related Groups (DRGs). DRGs relate medical conditions                                                             Financial Literacy
          engagement, care coordination, and ageing-in-place.           to resource use. This approach has helped facilitate fairer
                                                                                                                                                                                          Peace of Mind
          The CHTs are co-located within community facilities, and      allocation of resources as typical cases in a single DRG can
                                                                                                                                                                                          Positive Mindset, Social Cohesion and
          bridge care between public healthcare institutions and        be expected to have similar costs for treatment, thereby
                                                                                                                                                                                          Good Relationships, Dealing with Crisis
          the community. They aim to provide seamless transition        allowing funding subvention to be better correlated with
          for patients and caregivers from hospital to home, enable     resource needs1. Bundling payments for DRGs, either in the                                                        Contribution
          quality care in the community, and reduce the risk of         inpatient setting or across the spectrum of care, takes the                                                       Empowerment, Being a Person of Value,
          hospital re-admissions by:                                    optimisation of subvention funds one step farther.                                                                Peer Support

          • Empowering self-management of health issues through         Inpatient (AH-CH) bundles, which apply to all DRGs,                                                               End of Life
            coaching and relationship-building, which correlates with   serve to recognise the community hospital as an integral                                                          Dignity, Choices
            an increase in accountability and better health outcomes    part of inpatient care by taking acute hospital (AH) and

          • Delaying Frailty progression with early detection and
                                                                        community hospital (CH) stay as one episode for the
                                                                        patient. This allows for the shifting of resources across      ONE SET OF ASSESSMENTS
                                                                        the two settings. Inpatient (Full) bundles include post-
          • Providing case management and care coordination             discharge follow-ups with our community partners in the        Given the different measures of a person’s health status and needs across care settings, there are plans to
            services by acting as a single point of contact for         episode of care, and encourage holistic management of          establish common data gathering mechanisms, geriatric assessments, and Frailty indicators such as the
            patients and helping them organise and access the           patients regardless of the care setting. Central Health will   Clinical Frailty Score (CFS) for a more robust identification of our population health needs. This in turn
            various care support and resources required                 pilot a version of this in 2019 known as the Extended DRG      determines the design of our interventions and resource allocation.
                                                                        Plus Bundle.
                                                                                                                                       The Population Health Index (PHI), developed by NHG’s Health Services and Outcomes Research (HSOR)
                                                                                                                                       Department, is a unified metric that monitors the health of our population over time, based on the various
                                                                                                                                       domains that significantly contribute to health, namely, physical, mental and social functioning, health-
                                                                                                                                       related risk factors and historical healthcare utilisation rates. Baseline PHI measurements of the Central
                                                                                                                                       Zone were completed in 2017 and are being used to design and evaluate our healthcare interventions.

                                                                                                                                       5 DOMAINS OF SIGNIFICANCE                                           • Diabetes, Hypertension, Dyslipidaemia
                                                                                                                                                                                                           • Modified Barthel Index
          “THERE IS A RENAISSANCE IN                                                                                                                                                        Physical
                                                                                                                                                                                                           • Late Life Function and Disability Instrument

          HOSPITALS – A TIME WHEN                                                                                                                   •   Primary Care
          HEALTHCARE WAS DELIVERED IN                                                                                                               •   SOC
                                                                                                                                                                                                                                 • Dementia
                                                                                                                                                    •   ED                                                         Mental        • Montreal Cognitive Assessment
          THE COMMUNITY, DEPENDENT                                                                                                                  •   Admissions
                                                                                                                                                                       Utilisation                                               • Patient Health Questionnaire
          ON THE INTIMATE KNOWLEDGE                                                                                                                 •   Drugs
          OF LOCAL NEEDS, AND RELIANT                                                                                                                                                      Index
                                                                                                                                                              • Malnutrition                                            • Social Isolation
          PROFESSOR EUGENE FIDELIS SOH, CEO,                                                                                                                                      Risk                    Social
                                                                                                                                                              • Obesity                                                 • Loneliness

                                                                                                                                                                                 Figure 5: Population Health Index

27   © National Healthcare Group                                                                                                                                                                                                                © National Healthcare Group   28
03CHAPTER THE THREE ZONES - National Healthcare Group
          Preventive Care                                                                                    • The Community Influenza Vaccination Programme                                           Primary Care                                                   Decantment of Stable Patients from SOCs to Primary Care:
                                                                                                               was first launched as a three-year pilot in 2016 for
          The Preventive Care workstream facilitates a community-                                                                                                                                      The Primary Care workstream aims to establish effective        • The Community Right-Siting Programme (CRiSP)
                                                                                                               vulnerable seniors, aged 65 and above, living in rental
          driven approach to optimise the bio-psycho-social well-                                                                                                                                      Primary Care partnerships with the objective of anchoring        was launched in 2014 to manage medically stable
                                                                                                               units with the objective of reducing the risk of influenza
          being of the population. It champions upstream ownership                                                                                                                                     Primary Care as the first line of care in the community          patients with certain chronic conditions, such as
                                                                                                               infections. Future plans after the completion of the pilot
          of care through outreach and service as well as through                                                                                                                                      for appropriate right-siting of care. This, in turn, reduces     Asthma, Diabetes, Hypertension, Ischaemic Heart
                                                                                                               are to integrate influenza vaccination with functional
          activation. Key initiatives include:                                                                                                                                                         the demand for specialist services. Key partners engaged         Disease, and Stroke in the community. This is achieved
                                                                                                               screening events to enhance the accessibility of these
                                                                                                                                                                                                       through focus groups and collaborative working                   through patient education, financial counselling, shared
                                                                                                               health services to seniors.
          Outreach and Service:                                                                                                                                                                        committees include the polyclinics, GPs, and Family              care protocols and arrangements for the specified
                                                                                                             • The War on Diabetes Community Intervention                                              Medicine Clinics (FMCs) in the Central Zone. The efforts of      conditions, and monitoring of patients’ progress for
          • Screening activities in the community have been
                                                                                                               Programme, started in 2016, reaches out to residents                                    the workstream are focused on providing more support to          12 months after discharge to Primary Care. Besides
            provided since 2014, starting with screening for
                                                                                                               for health coaching and/or structured workshops on                                      Primary Care partners and removing obstacles to patients’        allowing seamless, patient-centred care, CRiSP aims to
            cardiovascular risk factors and eventually expanding to
                                                                                                               Preventing Diabetes, Weight Management, and Diabetes                                    discharge from the acute setting, facilitating smoother          increase SOC outflow and ease the discharge processes
            include functional screening and falls screening. Follow-
                                                                                                               Self-Management. These sessions supplement clinical                                     transitions between care settings for patients and the           from SOC to Primary Care. These efforts have shown
            ups are provided through multi-party collaborations with
                                                                                                               follow-ups and motivate residents to take charge of their                               decantment of stable patients from the acute hospital,           promising results. Since 2014, we have engaged over
            General Practitioners (GPs), the Silver Generation Office
                                                                                                               own health, thereby mitigating the burden of diabetes.                                  enhancing the capabilities of GPs through training, and          120 GP partners, right-sited over 3,200 patients, with a
            (SGO), and other community partners.
                                                                                                                                                                                                       fostering greater coordination between GP partners in            reduction of over 9,600 repeat visits.
          • Community Health Posts (CHPs) have been set up                                                   Activation of the Community:                                                              the Chronic Right-Siting Programme (CRiSP) and the
            in various locations across the Central Zone, and are                                                                                                                                      Central-North Primary Care Network (CN-PCN). Some key          Fostering Greater Integration with Primary Care Partners:
                                                                                                             • To encourage activation and ownership of health,
            managed by Health Coaches. Their objective is to                                                                                                                                           initiatives under the workstream include:
                                                                                                               the workstream engages community partners and                                                                                                          • Started in August 2018, the Coordinating & Advisory
            nudge residents towards sustained health-promoting
                                                                                                               their clients to co-develop and run programmes and                                                                                                       Care Team (CoACT) serves as a platform for continuous
            behaviours through coaching sessions on different                                                                                                                                          Outflow of Stable Patients from the Emergency
                                                                                                               activities, which meet the health and social needs of the                                                                                                interaction between the hospital and Primary Care
            topics, such as nutrition and healthy eating, physical                                                                                                                                     Department (ED) to Primary Care:
                                                                                                               community. This involves adopting Esther Networks2 as                                                                                                    providers with administrative and clinical support from
            exercise, blood pressure management, falls prevention,
                                                                                                               a methodology to facilitate focus group sessions and                                    • GP Next is an initiative that aims to reduce no-show           a tertiary care advisory group comprising specialists,
            and mental wellness. Launched in 2016, CHPs have
                                                                                                               the principles of the Five Bliss as a framework to get                                    rates at Specialist Outpatient Clinics (SOCs) and reduce       right-siting nurses, and right-siting coordinators from
            grown from three sites to 36 sites to-date.
                                                                                                               residents to reflect on what they value. This exercise                                    demand for SOC visits by discharging patients to GPs           all clinical specialties. This aims to facilitate smooth
                                                                                                               empowers them to create programmes that enable                                            for review after treatment at the ED.                          transitions of patients into the community.
                                                                                                               them to live and age well in the community.
                                                                                                                                                                                                                                                                      • GP Buzz is a quarterly corporate publication for GPs
                                                                                                                                                                                                                                                                        (as the primary audience) as well as polyclinics to keep
                                                                                                                                                                                                                                                                        them and their patients updated on the latest healthcare
                                                                                                                                                                                                                                                                        developments and services at TTSH, promote new and
                                                                                                                                                                                                                                                                        better care practices within the community, and foster
          FACILITATE A COMMUNITY-DRIVEN APPROACH TO                                                                                                                                                                                                                     stronger partnerships with GPs.
                                                                                                                                                                                                       ESTABLISH PRIMARY CARE PARTNERSHIPS TO
                                                                                                                                                                                                       REDUCE SOC-INFLOW AND INCREASE SOC-OUTFLOW

                                               Outreach and Service                                                  Activation of Community
                                             Collaborate with partners on                                            Co-development of community                                                                                                                                                      Integration
                                            needs identification, screening,                                         programmes and initiatives with                                                                                                  SOC to Primary Care
                                               and community activities                                                  partners and residents                                                             ED to Primary Care                                                                    Provide platforms for
                                                                                                                                                                                                                                                        Facilitate and increase
                                                                                                                                                                                                                                                                                               continuous liaison between
                                             (e.g. screening at Community                                                (e.g. Esther Networks,                                                            Reduce non-emergency                      outflow from SOCs through
                                                                                                                                                                                                                                                                                                 Primary Care providers
                                               Health Post, vaccination)                                                     Engage-in-Life)                                                                attendances at ED and                     discharges or shared care
                                                                                                                                                                                                                                                                                                 and hospital specialists
                                                                                                                                                                                                           demand for SOC (e.g. GP                     and supporting enablers
                                                                                                                                                                                                                                                                                               for supported and smooth
                                                                                                                                                                                                               Nearby, GP Next)                          centred around GPs
                                                                                                                                                                                                                                                                                                   transitions into the
                                                                                                                                                                                                                                                              (e.g. CRiSP)
                                                                                                                                                                                                                                                                                                community (e.g. CoAct)

                                                                            Figure 6: Preventive Care Objectives

                                                                                                                                                                                                                                                  Figure 7: Primary Care Objectives
           ESTHER Network Singapore aims to promote the philosophy of person-centred care and to train a pipeline of ESTHER Coaches to better serve our patients and their caregivers. ‘Esther’ is a
          symbolic person with complex care needs who requires the coordination and integration of hospital, Primary Care, Home Care, and Community Care services.

29   © National Healthcare Group                                                                                                                                                                                                                                                                               © National Healthcare Group   30
03CHAPTER THE THREE ZONES - National Healthcare Group
                                                                                                                                              FACILITATE CONTINUED REHABILITATION IN THE COMMUNITY

          Hospital Care                                                       Intermediate Care
                                                                                                                                                                                               Acute Hospital                               Integration
          We continue to provide evidence-based care pathways                 Some of our patients require extra care after a surgery or           Acute Hospital to
                                                                                                                                                                                               to Community
          that ensure timely access to quality and cost-effective             hospitalisation. The Intermediate Care workstream aims to           Community Hospital                                                                   Establish flexible patient
          care, while working closely with community partners                 establish an effective downstream rehabilitation system                                                    Improve turnaround time and                flows and capability building
          to ensure that patients return to optimal health and                for these patients that enables continued rehabilitation            Improve triage workflows
                                                                                                                                                                                          rate of successful placement                 (e.g. subsidised speech
          independent living. We are also building a more senior-             in the community and ensures access to the required                  and turnaround time for
                                                                                                                                                                                         in Day Rehabilitation Centres               therapy outpatient services
          friendly hospital to support our older and Frail population.        follow-up clinical services after an acute episode. The             discharges to CHs (e.g. CH
                                                                                                                                                                                         for continued rehabilitation in              for CH cases, AMK-THKH
          Some of the key objectives in this workstream include:              efforts of the workstream centre on collaboration with              VSM, direct transfers from
                                                                                                                                                                                              the community (e.g.                       nursing education and
                                                                              community hospitals and day rehabilitation centres to                       ED to CH)
          • Provide safe and coordinated care                                                                                                                                                       DRC VSM)                            training collaboration)
                                                                              improve processes to achieve quicker turnaround time
          • Ensure care remains accessible for our patients and               for transitions, and integrate care pathways to maximise
            population                                                        the effectiveness and efficiency of care in the sub-acute,
                                                                              intermediate-rehabilitation, and community-rehabilitation
          • Provide the best value to our patients and population                                                                                                                    Figure 8: Intermediate Care Objectives
                                                                              settings. Key initiatives by the workstream include:

          Initiatives by this workstream span across the emergency,           Optimising Acute Hospital (AH) to Community Hospital            Transitional and Community Care                                social support system and with Primary Care partners to
          inpatient, and outpatient settings. Some of these include:          (CH) Flows:                                                                                                                    establish the support essential for patients to stay well
                                                                                                                                              The Transitional and Community Care workstream
                                                                                                                                                                                                             in the community.
          • Emergency Department Interventions for the Frail                  • The CH Value Stream Mapping (VSM) was conducted               collaborates closely with the inpatient team to facilitate
            Elderly (EDIFY) – To meet the needs of older and/or                 with the objectives of improving triage workflows and         discharge planning and the smooth transition of care to      • In line with our culture of continuous improvement, this
            Frail patients attending ED, and to reduce the negative             turnaround time for discharges to CH. Through this VSM,       the community (either home or long-term care facilities),      workstream partners the inpatient discharge planning
            outcomes commonly experienced by older patients,                    AH to CH fast track flows were established for discharges     and with local partners to increase community days             team to improve discharge processes. These process
            EDIFY was developed to ensure that principles of                    to Ang Mo Kio-Thye Hua Kwan and Ren Ci CHs.                   through coordination of services, co-development and/or        improvements include standardising protocols for
            geriatric care can be delivered right from the point of                                                                           augmentation of community programmes, and training.            screening of discharge needs between the inpatient
            arrival at the ED. It provides early geriatric review in the      Optimising Acute Hospital to Day Rehabilitation Centre          These efforts are anchored by the CHTs. Key initiatives of     and community teams, engaging the Agency for
            ED with the primary aim of reducing potential avoidable           (DRC) Flows:                                                    the workstream include:                                        Integrated Care (AIC) and community partners to
            admissions among older persons.                                                                                                                                                                  standardise and streamline the referral process,
                                                                              • The DRC VSM was conducted to improve discharges               • TTSH’s Transitional Care service (now the CHTs) was
                                                                                                                                                                                                             and establishing open channels of communications
          • Geriatric Comprehensive Assessment and Rehabilitation               from TTSH to DRCs, to reduce the turnaround time for            established in July 2016 based on the key principle that
                                                                                                                                                                                                             across providers to improve information sharing and
            for Elders (GeriCARE) – GeriCARE is an important arm of             referrals and to improve the rate of successful placement.      every patient with complex care needs should have
                                                                                                                                                                                                             continuity of patient care.
            the hospital’s efforts to introduce geriatric principles in the     Initiatives from the future state design include                a single-point-of-contact (SPOC) to coordinate one
            inpatient setting across disciplines under the Framework            standardised checklists and information provision               care plan and support safe, coordinated, and timely        • Since October 2018, the workstream has started
            for Integrated Care for the Frail Elderly (FIFE). It seeks          on the value of DRCs to ensure appropriateness of               transition from the hospital to the community and            working with AIC, SGO, and our anchor partners on
            to implement an integrated process of systematic and                referrals, multidisciplinary templates for collective input     home. As the SPOC, CHTs work with various internal           Neighbourhood Block Mapping to identify at-risk
            comprehensive geriatric care services for Frail elderly             on recommendations for DRC as a discharge support               hospital stakeholders for the discharge planning and         households within the neighbourhood and establish
            inpatients regardless of the discipline they have been              service, and automation for extraction of reports               care coordination. Post-discharge, CHTs collaborate          co-management, data-sharing, and interventional
            admitted to. The GeriCARE team, a mobile geriatric                  necessary for referrals.                                        with community partners to help patients navigate the        workflows to support the needs of these households.
            assessment team, comprises geriatricians, Advanced
            Practice Nurses (APN), and an administrative coordinator.         Fostering Greater Integration with Rehabilitation Service
            The team works closely with the inpatient team to conduct         Providers                                                       COLLABORATE WITH LOCAL PARTNERS TO INCREASE COMMUNITY DAYS
            Comprehensive Geriatric Assessments (CGAs), formulate
                                                                              • To facilitate transition of patients among rehabilitation     BY ESTABLISHING PLACE-BASED COMMUNITY HEALTH TEAMS
            personalised geriatric care plans and recommendations
                                                                                facilities, workflows have been established for
            for early diagnosis of new geriatric syndromes, and
                                                                                subsidised outpatient speech therapy services for
            provide support in geriatric care delivery.
                                                                                patients discharged to CH, and discussions are on-going
                                                                                for collaboration on nursing education and training for                                                                                                     Integration
                                                                                capability-building and upskilling.                                                                           Community Care
                                                                                                                                                    Hospital-to-Home                                                                   Establish platforms for
                                                                                                                                                                                          Enable health engagement,                   data sharing to facilitate
                                                                                                                                                   Reduce ED attendances
                                                                                                                                                                                            care coordination, and                  co-management of patients
                                                                                                                                                 and re-admissions by easing
                                                                                                                                                                                          ageing-in-place (e.g. anchor              and care transitions among
                                                                                                                                                  care transitions (facilitated
                                                                                                                                                                                                partners, CHTs)                      a community of providers
                                                                                                                                                           by CHTs)
                                                                                                                                                                                                                                     (e.g. neighbourhood block

                                                                                                                                                                             Figure 9: Transitional and Community Care Objectives

31   © National Healthcare Group                                                                                                                                                                                                                    © National Healthcare Group   32
03CHAPTER THE THREE ZONES - National Healthcare Group
End-of-Life and Long-Term Care                                     • Programme Dignity, a collaboration between Central
                                                                               Health, Dover Park Hospice (DPH) and Temasek                 ACHIEVING A HEALTHY POPULATION
          The End-of-Life and Long-Term Care workstream aims
                                                                               Foundation Cares, is a first-of-its-kind initiative to
          to establish palliative care networks as Communities
                                                                               improve the quality of life for patients with advanced       The Central Health Model of Care seeks to achieve the                               H      BE
          of Practice that support End-of-Life (EOL) care in the                                                                            Five Population Health aims: Better Health and Better                            ALT         TT
                                                                               dementia and reduce their need for acute care. Under                                                                                                        ER
          community. Through a multidisciplinary approach, the
                                                                               this programme, a multidisciplinary palliative care team     Value with Better People delivering Better Care to build                       HE                   VA
          team works towards improving clinical care and building
                                                                               of doctors, nurses, medical social workers (MSWs) and        a Better Community.
                                                                                                                                                                                                                   TTE                            LU
          capabilities outside the hospital, lowering the burden
                                                                               AHPs visits patients in their home to provide medical                                                                             BE                                 E
          of care through pain management, supporting psycho-                                                                               Within the Central Zone, we design and evaluate our
                                                                               and social care, as well as to train caregivers (for more
          social and financial needs, providing emotional support to                                                                        interventions and programmes by consistently mapping
                                                                               information, see p.93).
          patients and caregivers, and facilitating dignified deaths                                                                        to the Population Health Aims and the River of Life, as

          aligned with the values and wishes expressed by patients.                                                                         well as by monitoring and studying relevant indicators of
                                                                             EOL Care in Nursing Homes (NHs):

          Some key initiatives include:

                                                                             • Established in September 2009, the Project CARE
                                                                                                                                            Our work in Central Health builds on TTSH’s long and

                                                                               (Care at the End-of-Life for Residents in homes for the

          Advance Care Planning (ACP):                                                                                                      enriching journey in healthcare by bringing our efforts
                                                                               Elderly) team partners seven Nursing Homes to help
          • Since 2011, we have collaborated with AIC to scale                                                                              beyond the walls of our hospital. It challenges us to

                                                                               residents pass on with dignity. The team does this by

            up ACP provision within the hospital. We have gone                                                                              collectively lead, at every level of the organisation, build

                                                                               patient reviews, honouring residents’ values and choices
            upstream to initiate ACP discussions early, such as in                                                                          trusting and long-term relationships with our population

                                                                               with regard to EOL care through the facilitation of ACP
                                                                                                                                            and our partners, so that we can continue to fulfil our

            polyclinics, FSCs, and other community settings, where
                                                                               and Preferred Plan of Care (PPC) discussions, improving
            patients feel less vulnerable and are more likely to be                                                                         laudable purpose – to serve, care, and heal – long into
                                                                               the satisfaction of their families with EOL care delivery,
                                                                                                                                            the future.
            receptive to the ACP conversation. We are also working
                                                                               and building the capabilities of NH staff through training                                                                                     BETTER CARE
            to include more illnesses (i.e. other than cancer)
                                                                               in EOL areas.
            that require the initiation of ACP discussions, such as
            cardiovascular, renal, and respiratory conditions (for           • Established in May 2017, the Nursing Home Roadmap
            more information, see p.92).                                       involves working with NH partners to jointly develop
                                                                               and implement interventions and preventive measures
          Home Palliative Care:                                                to improve the NHs’ capabilities through training and
                                                                               upskilling of staff.
          • Programme IMPACT (Integrated Management and
            Palliative Care for Terminally Ill patients) is our palliative
            home care initiative for patients who have End-Stage
            Organ Failure (ESOF). Programme IMPACT leverages
            on close partnerships between hospital specialists
            and the home care teams in the community (for more
            information, see p.93).

                                                                                                                                            “WHEN WE ENLIST PATIENTS AS OUR
          ESTABLISH PALLIATIVE CARE NETWORKS AS COMMUNITIES                                                                                 PARTNERS, THEY BECOME OUR EYES AND
          OF PRACTICE SUPPORTING EOL CARE IN THE COMMUNITY                                                                                  EARS, OUR SOUNDING BOARD, AND VOICE
                                                                                                                                            OF REASON. BRINGING PATIENT-CENTRED
                                                                                                                                            CARE TO FRUITION REQUIRES A SHIFT NOT
                                                                 EOL Care in
                                                                                                                                            JUST IN OPERATIONS BUT IN CULTURE. THIS
                                                                                                       Quality Improvement                  JOURNEY HAS BEGUN AND WE LOOK FORWARD
               Home Palliative Care                             Nursing Homes
              Support seamless transition                     Support EOL care in
                                                                                                        Reduce hospital utilisation         TO BUILDING AN ENVIRONMENT THAT
                                                                                                         and transfers of care for
                 of terminally-ill ESOF                      Nursing Homes through
                                                                                                         Nursing Home residents             TRANSFORMS THE HEALTHCARE EXPERIENCE
               patients between hospital                   upstream identification of
              and home (e.g. Programme                     needs, information sharing,
                                                                                                         (e.g. care paths and care          FOR PATIENTS, AND PROVIDES THEM WITH
                                                                                                          bundles under Nursing
                        IMPACT)                             and capability-builing for
                                                                                                             Home Roadmap)
                                                                                                                                            CARE THAT THEY TRULY VALUE.”
                                                            staff (e.g. Project CARE)
                                                                                                                                            PROFESSOR EUGENE FIDELIS SOH,
                                                                                                                                            CEO, TAN TOCK SENG HOSPITAL & CENTRAL HEALTH

                                                Figure 10: EOL and Long-Term Care Objectives

33   © National Healthcare Group                                                                                                                                                                                                            © National Healthcare Group   34
03CHAPTER THE THREE ZONES - National Healthcare Group
          LIFELONG CARE IN SUPPORTED SELF-MANAGED COMMUNITIES                                                                                        01                               02                                03                             04
          It takes a village to raise a child, and likewise, a community   to where residents live, and it has since become a familiar
                                                                                                                                             Decentralise                      Democratise                    Disintermediate                       Diminish
          to support every resident. Yishun Health (YH) aims to            face, whom the residents trust. Team members are
                                                                                                                                          • Restructure authority           • Let go of control in order      • Peer as first responder       • Light touch
          transform and support our Yishun neighbourhoods                  familiar with the residents’ needs, as well as their assets,
                                                                                                                                                                              to engage                         for those in need
          as self-managed communities. Such communities are                aspirations, and how health relates to those aspirations.
                                                                                                                                          • Programmes and                                                                                    • “Stealth health”
          designed as ecosystems where services are developed              In such ecosystems, our hospital and its services form the
                                                                                                                                            activities (other than          • Group decision-making,          • Disintermediated access
          in tandem with building the residents’ capability and            ‘last’ layer of support – a safety net for residents during
                                                                                                                                            health-related) are               shared responsibility             to solutions, such as
          capacity for self-care. In these ecosystems, YH supports         medical crises to assist them to return to a supportive
                                                                                                                                            executed from the                                                   referrals by peers to
          residents to manage their own health and to navigate             community which continues with their care.                                                       • Shared common
                                                                                                                                            ground up                                                           experts
          the ‘formal’ healthcare system to access care at the                                                                                                                resources, such as space
                                                                           In this journey from a hospital-centric to an ecosystem
          right touchpoints, and at the lowest cost to self and
                                                                           approach, the team has changed its mindset for the way it
          system. To do this, its Population Health and Community
                                                                           interacts with residents. Today, the team operationalises,
          Transformation (PHCT) team emphasises and engages
                                                                           implements, and coordinates programmes not as experts                                         Figure 1: The 4 “D”s of Asset Based Community Development
          Yishun residents’ ‘informal’ layers of social support –
                                                                           ‘rescuing’ patients from crisis, but as equal members of the
          networks of family, neighbours and friends – whom
                                                                           Yishun community. These beliefs now form the foundation
          residents can count on for managing their health and
          addressing social challenges. The team makes itself more
                                                                           of our work in holistic community development.
                                                                                                                                          THE RIVER OF LIFE IN YISHUN
          visible and accessible at nodes in the community, close
                                                                                                                                          To strengthen our interactions with the community, YH               80:20 Principle
                                                                                                                                          collects and analyses data to spot patterns and trends
                                                                                                                                          about Yishun’s residents and the environment. On average,           80 per cent of residents in the community have simple
                                                                                                                                          patients in the North are six years younger than patients           issues, and they have existing capabilities and capacities
                                                                                                                                          in the Central Zone. They experience chronic disease and            which can be strengthened and supported for better self-
                1. Facilitator, not provider                                    2. Focus on actions that create                           Frailty at a younger age. If residents spend more years             management. The remaining 20 per cent have complex
                                                                                   behavioural change                                     with illness and Frailty, the North will face a potentially         medical, psycho-social, and economic needs which require
                As healthcare professionals, we are quick to rush                                                                         higher healthcare burden. However, the North Zone is also           targeted interventions and regular monitoring.
                to residents’ aid and prescribe solutions. We miss              Healthcare professionals find it easy to impart           blessed with a younger population as new townships and
                the hidden strengths, assets, and resources that                knowledge – but this is only the first step. Action       more HDB flats are being built. This means YH has a longer          For example, in the North Zone, rental flats are increasing
                exist within the community. We should explore                   is needed to improve health and function. We              runway to build supported communities, shape lifestyles,            steadily, with one/two-room flats being built at a faster
                and activate layers of support surrounding each                 need to emphasise actions that can become                 and delay or prevent the onset of chronic disease and               rate than in the Central Zone. These flats tend to be
                individual before resorting to medical care.                    habits and routines.                                      Frailty in Yishun. YH is therefore investing in preventive          occupied by residents who are socially at-risk, younger
                                                                                                                                          health to help residents live well without disease, where           families (people in their 30s-40s, with young children) with
                                                                                                                                          possible.                                                           complex psycho-social issues, and older persons who are
                                                                                                                                                                                                              socially isolated. Many of these issues are accompanied
                                                                                                                                          Premature death among people with mental disorders                  by ill health. YH therefore implements person-centred
                3. Individually good,                                           4. Delivery to the last mile                              occurs about 20 years earlier than the general population.          interventions that take into account residents’ social
                   even better as a team                                                                                                  The life expectancy of 891 Institute of Mental Health (IMH)         determinants of health.
                                                                                Closing the last mile in care delivery is potentially
                We tend to support the highest trained team                     the most difficult part but will also likely make         patients who died between 2015 and 2016 was 64.3 years,
                member to maximise his/her productivity. We                     the most difference, particularly for those who           compared with the national average life expectancy of               In summary, YH believes in helping residents maximise
                can do more as a team. Every team member                        have lower access to resources. We can achieve            83.1 years. Half (50.6 per cent) of these individuals with          their wellness no matter where they are in the River of Life.
                adds value to care directly, increasing care                    this better at the neighbourhood level. We often          mental illness also have chronic diseases. However, most            Residents can aspire to Live Well, Live Well with Illness,
                access to multiple touchpoints.                                 ask ourselves, “Did ‘uncle’ get it?”                      of them are unwilling to seek treatment or default on               Live Well with Frailty, and Leave Well, supported in self-
                                                                                                                                          medical appointments due to social stigma.                          managed communities.

                                                                                                                                          Everyone universally wants to live well, even if he/she is
                                                                                                                                          chronically ill, mentally ill, or Frail. These residents desire a
                                                                                                                                          better quality of life just as much as their healthier peers.
          Put into practice, these beliefs translate into the 4 “D”s       under-used spaces can be transformed into places where         With the support of their communities, they are able to
          of community development: Decentralise, Democratise,             the community can gather and get out of social isolation.      live with more dignity and independence. Small crises
          Disintermediate, and Diminish. With the 4 “D”s, YH               Kampung buddies are sociable residents who volunteer to        become easier to manage adequately without formal help.
          recognises that people are the experts of their own lives.       deliver meals so that they can meet their neighbours and       If the PHCT team goes further to nurture the communities’
          Therefore, it is not the role of a healthcare professional to    keep active. The engaged community grows to become             capability and capacity, residents can go beyond a life
          dictate the everyday choices that people make. Instead,          an environment rich with everyday opportunities for            of sufficiency to aspire for a better life. Residents can
          healthcare professionals are facilitators who uncover            residents to support each other in managing their health       contribute to these aspirations and find new meaning in
          residents’ strengths, assets, and resources. These are the       at a place that is close to them. This process is known as     their lives. They transform from being passive receivers
          raw materials which the facilitators leverage to build the       Asset-Based Community Development.                             to active contributors who seek to live well, regardless of
          capacity and capability of the community. For example,                                                                          their state of health, to the End-of-Life.

35   © National Healthcare Group                                                                                                                                                                                                                         © National Healthcare Group   36
03CHAPTER THE THREE ZONES - National Healthcare Group
          Community Nurses represent healthcare in the community. Embedded in regional teams, they are “health buddies”,
          supporting our residents at every stage of the River of Life via a whole population approach. They are given the              LIVING WELL (WITHOUT ILLNESS OR FRAILTY)
          autonomy to practise at the top of their licence, and to create and implement care plans according to residents’ needs
          and aspirations. They also manage YH’s residents with diverse health and psycho-social needs in community-based               To help Yishun residents live well without illness or Frailty for as long as possible, YH focuses on preventive health strategies.
          spaces or in their homes.                                                                                                     These include regular chronic disease and functional screening, and healthy lifestyle change through promoting health
                                                                                                                                        literacy and “stealth health”. The team leverages opportunities to introduce preventive health to residents where they
                                                                                                                                        spend most of their time: at school, at work, and in the community (for those not in school or working).
          Referral & Resource                Care Goals                                CFS
          Home Visits, Nursing               • Palliative Care                            9          Terminally Ill
                                                                                                                                        At School                                                         At Work
          Home                               • Equip Informal Networks
          e.g. AIP-Palliative Care Team,                                                   8         Very Severely Frail                Healthy habits inculcated from a young age last a life            Since November 2010, Khoo Teck Puat Hospital (KTPH)
          IMPACT, EOL Care Agencies          •   Caregiver Support                                                                      time. At a young age, students are easily influenced by           as the anchor hospital in Yishun has been established
                                             •   Home Modification, Assistive Aids         7         Severely Frail                     teachers, who are their role models whom they spend               as a ‘Health Promoting Hospital’. Its care philosophy of
                                             •   Advance Care Plan                                                                      much time with. YH has engaged the Ministry of Education          “a sound mind in a sound body” is reflected in its work-
                                             •   Flu & Pneumococcal Vaccination           6          Moderately Frail                   (MOE) to identify opportunities to transform teachers             life efforts and activities, embodied in the Five Pillars
                                                                                                                                        into health ambassadors for their students. An example of         of Health values. These values guide the creation of an
          Home Visits                        • Geriatric Assessment                        5         Mildly Frail                       this collaboration is the conduct of Group Health Report          environment – from within and without – that supports
          e.g. AIP-CCT, VWO                  • Reduce Social Isolation                                                                  Reviews (GHRR) for MOE’s teaching and non-teaching                the health of its staff, patients, as well as the community
                                                                                                     Vulnerable                         staff after their health screening exercise. The reviews help     it serves. The Five Pillars of Health are (1) Eat wisely, (2)
          Pro-active Home Visits             • Link to Primary Care                                                                     teachers understand their health reports, and recognise           Exercise regularly, (3) Be happy, (4) Stop smoking, and
                                             • Health Coaching                                       Managing Well                      early warning signs of chronic disease. GHRR is further           (5) Practise personal hygiene. Current population health
          Centre-Based Spaces                • Supported Self-Management                                                                supplemented by two e-Tools: a Health Risk Assessment             improvement efforts are mapped onto the Living Well
          e.g. Wellness Kampung, CNPs,                                                               Well                               and a disease Trajectory simulation. With the e-Tools, MOE        3E5P Framework to build a Culture of Health – promotion
          Share A Pot®, GPs, VWOs            • Vaccination                                                                              staff can visualise their health risks and chronic disease        of Education (‘I know how to’), Empowerment (‘I am able
                                             • Functional Screening                                  Very Fit                           trajectories in comparison with their peers. The feedback         to’) and Engagement (‘I want to’) at the individual level,
                                                                                           1                                            and peer comparisons motivate at-risk MOE staff to take           and driving improvements in these 5 aspects – Place
          Community Spaces                   • Chronic Disease Screening
          e.g. GROs, VWOs, Walk-In                                                                                                      early action and prevent chronic disease. The e-Tools were        (environmental nudges), Process (choice architecture),
                                                                                                                                        co-developed with NHG’s Health Services and Outcomes              People (role modelling), Policy (social norm), and
                                                                                                                                        Research (HSOR) Department.                                       Promotion (health awareness).

                                                                                                                                        “AT YISHUN HEALTH, WE BELIEVE THAT OUR ROLE IS NOT
                                                                                                                                        JUST ABOUT BRINGING HEALTH TO PATIENTS WITHIN OUR
                                              Figure 2: Yishun Community Nursing Framework
                                                                                                                                        HOSPITAL, BUT TO SERVE THE GREATER COMMUNITY.
                                                                                                                                        INSTEAD OF TREATING DISEASE IN AN EPISODIC WAY, WE
          Community Nurses help residents navigate formal and             resources at the local neighbourhood level, and allow
          informal resources available in the community. Formal           residents to get support through trusting relationships.      ARE MOVING UPSTREAM TO HELP PREVENT DISEASES AND
          services encompass Primary Care providers, Day Care
                                                                          Geographically-based Community Nursing has been YH’s          COMPLICATIONS, AND EMBRACING WELLNESS ALONGSIDE
          Centres, Senior Activity Centres, and Family Service
          Centres, and address residents’ medical, social, or financial
                                                                          backbone of care since 2012. In the following sections, the   ILLNESS CARE.”
                                                                          roles of Community Nurses in the context of the River of
          needs. Informal resources such as support groups,
                                                                          Life’s segments of care are explained in detail, alongside    MRS CHEW KWEE TIANG, CEO, KHOO TECK PUAT HOSPITAL & YISHUN HEALTH
          neighbours, and local merchants complement formal
                                                                          the other programmes managed by PHCT.

37   © National Healthcare Group                                                                                                                                                                                                                       © National Healthcare Group   38
THE FIVE PILLARS OF HEALTH                                                                                                     IN THE COMMUNITY
          Eat Wisely                                                     Senior Management gives staff emotional and                     Community Screening                                              Mini Medical School
                                                                         psychological support, and various wellness programmes
          Healthy eating is crucial in managing weight, improving                                                                        An estimated 40 per cent of residents in the North have          Mini Medical School (MMS) is a “school” for the people, by
                                                                         provide variety to the work day and helps them pursue
          productivity at the workplace, and reducing the disease                                                                        an underlying chronic condition they are unaware of. To          the people. It is a ground-up initiative dedicated to making
                                                                         their personal interests, hobbies, and aspirational skills,
          burden, especially diabetes and coronary heart conditions.                                                                     identify and address chronic disease and Frailty early,          medical science education accessible to the public,
                                                                         instilling confidence in their work. Light-hearted, fun and
          YH seeks to be a role model in influencing the dietary                                                                         the PHCT team organises chronic disease and functional           raising health literacy and self-efficacy, and activating the
                                                                         positive messages are placed around the YH campus to
          choices of its staff, patients, visitors, and the community.                                                                   screenings in the community for residents. Screening             community to become life-long learners and active co-
                                                                         bring smiles to the faces of patients, visitors, and staff.
                                                                                                                                         is done at ‘third places’ where people gather, such as           managers of health.
          At KTPH’s and Yishun Community Hospital’s (YCH) food
                                                                                                                                         marketplaces and Community Clubs.
          courts, an 80:20 rule applies – 80 per cent of food items      Stop Smoking                                                                                                                     Six lectures are delivered over three consecutive
          and drinks served are a healthier choice, and 20 per cent                                                                      At present, residents above 40 years old are screened for        Saturdays, with a graduation ceremony on the final day
                                                                         Negative effects of smoking are well-documented and
          are less healthy options, to subtly influence and encourage                                                                    chronic disease via the national Screen for Life programme.      where certificates of attendance and graduation gifts are
                                                                         quitting is the only effective way for a healthy lifestyle.
          patrons to make more deliberate choices. Healthier                                                                             The team hopes that residents at risk of chronic disease are     presented to the ‘students’ as a form of encouragement
                                                                         KTPH and YCH are smoke-free premises, including the
          Choice meals – which are less than 500 kcal per serving                                                                        spurred to action via their screening results. One strategy      for completing the course. Speakers are professionals
                                                                         outdoor areas and the Yishun Pond. “No Smoking” signs
          – are displayed prominently on menu boards, and brown                                                                          it uses is social pressure. It encourages residents to collect   from the healthcare industry and other related fields.
                                                                         are peppered throughout the hospitals, and smoking
          rice is served as the default and cheaper carbohydrate                                                                         their chronic screening report at GHRR sessions. During          Their lectures are engaging and informative, and they
                                                                         cessation programmes are organised to help smokers
          source. Sugared drinks are also more expensive to prompt                                                                       these sessions, Community Nurses explain the screening           seek to simplify and explain medical jargon to the layman
                                                                         kick the habit. Staff are encouraged to lead by example
          patrons to opt for cheaper, less sweet beverages. The                                                                          results to groups of residents in a classroom setting.           without compromising the depth of the content. Topics
                                                                         – by being non-smokers themselves – and empowered to
          intent is to give them healthier options and nudge them                                                                        Residents who attend can compare their results with their        cover ‘changes in the brain and its function over time’,
                                                                         tell smokers to stub out, thus ensuring that patients and
          towards more nutritious food and beverage choices using                                                                        screening cohort to gauge their level of risk in relation        Frailty, nutrition, preventive health, oral and bone health,
                                                                         visitors have fresh air and a clean environment.
          differential pricing and strategic placement.                                                                                  to the norm. Alternatively, at-risk residents are able to        geriatric syndromes, sleep, pain management, microbes
                                                                         Practise Personal Hygiene                                       collect their health report from Primary Care partners in        and health, surgery, and metabolic syndrome.
          Exercise Regularly                                                                                                             the community so that they can be counselled and guided
                                                                         Good personal hygiene is a fundamental tenet of YH’s                                                                             Since 2013, 14 runs of MMS have been conducted and
                                                                                                                                         on how to change their lifestyles to avoid chronic disease.
          Exercise has a positive influence on health. Sometimes         culture, especially with the close proximity to the                                                                              they drew over 4,000 attendances, with more than 1,990
                                                                                                                                         In addition to ‘third places’, the PHCT team also operates a
          it is difficult to find the motivation to exercise, so YH      surrounding HDB neighbourhoods. This nexus between                                                                               unique ‘students’. MMS continues to appeal to a wide
                                                                                                                                         booth at the KTPH Lobby every weekday morning where
          incorporates exercise into daily routine and practical         the residents and hospitals creates high potential for                                                                           range of students, aged between nine and 89, with the
                                                                                                                                         there is steady stream of human traffic. Residents can
          activities through simple steps. For example, taking           infection, with contagion potentially ‘flowing’ in either                                                                        majority being 50 to 70 years old.
                                                                                                                                         come for chronic disease screening at their convenience.
          the stairs instead of the lift is encouraged with health       direction – from the hospitals to the community or vice         From 2013 to 2018, 26,000 residents were screened.
          messages and prominent location of stairs.                     versa. In addition to promoting hand washing compliance
                                                                         to staff, efforts to Practise Personal Hygiene include “self-   A decline in eye, ear, and oral health can adversely affect
          Daily exercise and mass workouts for staff and residents
                                                                         cleaning” where people are encouraged to pick up any            one’s quality of life. Residents above 60 are therefore
          of all ages are also organised to reinforce the benefits
                                                                         litter and be responsible for themselves at the food courts     screened for age-related decline in these areas. If there is
          of exercising to prevent or reduce the risk of chronic
                                                                         and other facilities. Staff also participate in grassroots      decline, they are referred for the second level screening,
          conditions. Participation by families and friends is
                                                                         litter-picking events.                                          diagnosis, and treatment (such as the need for assisted
          encouraged and modified exercises for the elderly and
                                                                                                                                         devices). Since this programme launch in March 2018,
          wheelchair-bound are available too.
                                                                                                                                         more than 5,000 residents have been screened.

          Be Happy                                                                                                                       The information and profiles gained about our residents from
                                                                                                                                         community screenings facilitate planning, development,
          ‘Better People, Better Care’ is one of NHG’s River of Life
                                                                                                                                         and evaluation of population health initiatives.
          Better Care principles, and emphasises the need to care
          for and grow our people. It aligns with YH’s drive for a
          positive psychology in the workplace built on the notion
          that happier employees are more productive and more
          innovative, and hence the need to encourage joy in and
          at work. It also recognises that working in hospitals can
          be emotionally and physically challenging, and it can be
          difficult to maintain a cheerful disposition throughout the
          entire work day.

39   © National Healthcare Group                                                                                                                                                                                                                     © National Healthcare Group   40
You can also read