building self-supported community ecosystems self-supported community... · 2018. 11. 23. · •...

Building Self-Supported Community Ecosystems Mr Lau Wing Chew

Chief Transformation Officer, WHC

Members of National Healthcare Group

• Opening from 2022 • Comprises of a General Hospital,

Community Hospital , Specialist Outpatient Clinic and Nursing Home

• Up to 1800 beds

CAMPUS OVERVIEW

Northwest aerial view of Woodlands Health Campus

Woodlands Health Campus Mission Statement

Everything we do is about caring for

and improving the lives of our patients, community and healthcare family.

Our Community Mission

To create self-supported ecosystems to empower our community to manage their

health and age in place – building a resilient population and a thriving community.

Woodlands & Sembawang Towns (URA Master Plan 2014)

329,910 RESIDENTS (excluding non-residents)

Setting in the North

YOUNGER Age ≥ 65 years old WDL + SBW: 7.5% National: 11.8%

M O R E M A L AY S & I N D I A N S

WDL + SBW: 32.9% National: 22.4%

HDB DWELLERS

WDL + SBW: 92% National: 80% Source: Population Trends 2014 & 2017

49% : 51% ratio between those who are aged below 65 and above 65

Top healthcare utilisers in Woodlands & Sembawang Top 20% of patients utilise 84% of healthcare costs Top 5% of patients utilise 57% of healthcare costs

1

While the North is younger, proportion of top utilisers with chronic conditions or are frail is comparable to the Central

2

Top utilisers of Malay, Indian and Other ethnicities are mostly < 65 years old and has a higher proportion with chronic conditions

3

Identification of precincts of interest based on population demographics and

health utilisation data

NHGP

WHC

AdMC

Woodlands Planning Area

Correlation of social determinants of health to healthcare costs

Source: Montefiore Health System, The King’s Fund 2018

Community Analysis (Sensing)

Nurses in the Community

(Clinical/Care & Coordination)

CHOPE - Partnership - Volunteers

- Funding (Strengthening)

Community Programs

(Strengthening & Coordination)

Tact

ics

Engage to Understand

Engage for Partnership

(Co-creation, Funding & Volunteers)

Engage for TOMA (Top of mind awareness)

Engage for Collaboration

Stra

tegy

Sense needs & capabilities

Strengthen capabilities of the community

Providing accessible

Clinical/Care touch points Coordinate seamless care

navigation & resources

Go

al

To create self-supported eco-systems, to empower our community to manage their health and age in place - building a resilient population and a thriving community.

Overview of Strategy

NHGP

WHC

AdMC


Sensing through data analytics| Heatmapping


• Oldest flats • Cluster of rental flats • High socioeconomic needs • High hospital utilisation

• New rental flats and studio apartments • High socioeconomic needs • High hospital utilisation

• Old rental flat and new studio apartments • High socioeconomic needs • High hospital utilisation

• New studio apartment • High chronic disease

prevalence

Hospital Data

KTPH (2017) • A&E: 3 A&E visits • AH ward: 4 admissions, Total LOS: 43 days • SOC: 1 visit to Cardiology Clinic • YCH ward: 1 sub-acute admission

56 years old Female

High Utiliser

Case Study 1

Sensing through outreach| Building a more holistic view Referred to

Community Nurse for home visit


Outreach Data

Social • Separated, homemaker • Staying in rental flat with 1

adult son • Does not enjoy living in this

community • Stays at home • Does not exercise regularly • Currently home-bound as her

motorised scooter (obtained for free) is spoilt and not repaired due to cost

Financial • Public Assistance, CHAS • Worried about medical

expenses Self-rated health (scale of 4) • 1 (very poor)

Medical conditions • Diabetes (on insulin) • High Cholesterol • Hypertension • Ischaemic heart disease • Left BKA Follow-up • Woodlands Polyclinic • KTPH Problems with managing health • Appointments – wheelchair-

bound, require taxi • Medication – require son to

prepare medication • Knowledge – cannot

understand doctor’s instructions and explanation without son’s assistance

Interviewer notes: CFS 7

Hospital Data

KTPH (2017) • A&E: 37 A&E visits • AH ward: 15 admissions, Total LOS: 45 days • SOC: 17 SOC visits (1 Anae, 1 Cardio, 8 Dental, 4 Med, 3 Surg)

51 years old Female

High Utiliser

Case Study 2

Referred to CN for assessment

Sensing through outreach| Building a more holistic view


Outreach Data

Social • Divorced, unemployed (used

to be a nurse) • Staying in rental flat with

mother and ex-boyfriend • Enjoys living in this

community • Stays at home, Family,

Shopping • Does not exercise regularly • Enjoys cooking, singing, art

and craft, community service Financial • Public Assistance, MFEC • Worried about daily expenses

and housing bills

Medical conditions • Diabetes • High Cholesterol • Liver Cancer • Asthma Follow-up • GP clinic • KTPH SOC Problems with managing health • Appointments • Accessibility to services Interviewer notes: CFS 3 • Cheerful lady though multiple

co-morbidities, manages her conditions well

Community Assets around Blk 764B Golden Saffron Postal Code

Sunlove Senior Activity Centre 732764

Sree Narayana Mission Senior Care Centre

730861

• NTUC Health Active Ageing Hub • NTUC Health Senior Care Centre

730676

HCA Hospice Care (Woodlands Centre) 730672

CHAS GPs • Banyan Clinic Pte Ltd. • Central 24-Hr Clinic (Woodlands) • My Family Clinic (Woodlands) • Singapore Family Clinic & Surgery • Dr Nah & Lee Family Clinic • Admiralty Family Clinic • Yim Medical Centre (Admiralty)

730768 730768 730768 730717 730780 731678 730678

Care Corner Family Service Centre (Admiralty)

730718

Resident Committee

• Woodlands Zones 5, 6, Sembawang Zone E, G • Woodlands Zones 2, 4 & Sembawang Zones D, H, J

Lighthouse Evangelism Woodlands 738909

Schools • Admiralty Primary School • Evergreen Primary School • Riverside Primary School • Admiralty Secondary School • Evergreen Secondary School

738907 738908 737803 737916 738489

• Woodlands Mart • Admiralty Place • Kampung Admiralty

730768 730678 730676

Admiralty Secondary

School

Riverside Primary School

Admiralty Primary School

Evergreen Secondary

School

Evergreen Primary School


Sensing for partners| community assets mapping

Natural neighbourhood

Identifying potential ground partners and spaces

Living environment


Sensing on the ground| Seeing opportunities and challenges

SARS quarantine facility

Rental Flat

Hostel for workers

Drug addicts hideout Murder

Paranormal activity

Articles

Forums

Websites

The Philosophy Building Brain, Brawn, Bones & Bonds

Share a pot is a community-based project to improve the nutrition and fitness of community-dwelling seniors.

Community Programs


A community that supports healthier living Wellness Kampung is an initiative comprising a network of three wellness and care centres for residents in the north. Our Wellness Kampung provides a suite of health and social programmes, creating a support network for residents to inspire each other to adopt healthier lifestyles, in a close-knit 'kampung' setting. WHC will be setting up similar facilities for communities in Woodlands Source: ktph.com.sg/wellness-kampung

Chope by Christchurch Sec

Chope by Faith-based Organisations

EMPATHY

Chope by Woodgrove Sec

INTER-GEN

Chope by Evergreen Sec

“NUKA”

SOCIAL SUPERMARTKET

Creating and building a Community of Hope in the North

Chope by Corporates (Launching in Sep)

Desired outcomes for CHOPE X Schools Influencing behaviour changes in self | Influencing behavioural changes in the family | Increasing volunteerism in community | Public service as choice of career



Woodlands

Secondary School

Share A Pot Launched 5 Apr at

Marsiling Zone 3 RC

SELF-SUPPORTED COMMUNITIES

Canberra

Secondary School

Share A Pot Launched 25 Jun at

Sunlove SAC

(764B Golden Saffron)

Enhanced Share a Pot (WIP) • Hydroponics systems for schools –

sponsored by corporate donors • Farm to table



Postcard with profile of local Community Nurse and services

Pocket-size localised resource guide for Community Nurses

Community strategy| building strong communities

NHGP

WHC

AdMC


Community strategy| building strong communities

Building new CNPs, Share a Pot and Wellness Kampung sites by 2020


Nurses work SMART (Clinical/Care & Coordination)



Community Programs


Community Screenings

Business Analytics

Mapping & Outreach

Community Nursing & Nurse Post

Hospital to Home

(AIP-CCT)

CNS, SGO, CFC

GP & Home Health

Support

Schools

Businesses

Wellness Kampungs

Share a Pot/ Our Kitchen

Community Health &

Social Partners

Community Gym

Tact

ics

Engage to Understand

Engage for Partnership

(Funding & Volunteers)

Engage for TOMA (Top of mind awareness)

Engage for Collaboration

Stra

tegy

Sense needs &

capabilities

Strengthen capabilities of the

community

Providing accessible

Clinical/Care touch points

Coordinate seamless care navigation &

resources

Activities

Go

al

To create self-supported eco-systems, to empower our community to manage their health and age in place - building a resilient population and a thriving community.

Overview of Strategy

Religious Org

Tele-health support

Known to Hospital (Hospital Registry)

Known to Community

Nurses (CN

Registry)

Pre-Hospital Tele-triage • GP / OPS / UCC / ED • Activation of CN based

on criteria

Discharge Support • Discharge planning ‘Triage

Office’ support • Discharge calls (introduce

community programmes) • Tele-follow up (AIP-CCT) • Vital signs monitoring

In-hospital Support • Push data from CN Registry to Hospital

System/CRM upon contact with hospital services • Trigger admission alert to relevant CN team

Unknown

Regional Population Registry Contact Centre Support Business as Usual • Appointments • Enquiries

Our work in the community

Linking back to our hospital


Nurses work SMART (Clinical/Care & Coordination)



Community Programs


Community Screenings

Business Analytics

Mapping & Outreach

Community Nursing & Nurse Post

Hospital to Home

(AIP-CCT)

CNS, SGO, CFC

GP & Home Health

Support

Schools

Businesses

Wellness Kampungs

Share a Pot/ Our Kitchen

Community Health &

Social Partners

Community Gym

Religious Org

Tele-health support

To reach out to various community assets and create common goals to work together

(Local religious institutions, business retailers, GPs, ILTC providers, VWOs, schools etc)

To understand the community

(Work closely with HDB, town councils, grassroots, SGO and thorugh door-to-door outreach)

To enable the community to be self-sufficient

(Co-creation/adoption of programmes with local champions, businesses, schools and

corporate sponsors)

We may have found the methodology of 2S2C

But the work is continuous..

Thank You

building self-supported community ecosystems self-supported community... · 2018. 11. 23. · •...

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