TTSH Community Health Teams

Our Journey in Managing Frequent Admitters

2008

2012Post-Acute Care @Home

• Rehabilitate and monitor patients with assessed clinical or nursing need post-discharge

• Promote caregiver competence in managing homebound patients

Aged Care Transition

• Complex care coordination• Ease transitions of patients back to

the community and prevent readmissions

Virtual Hospital• Targeted at frequent admitters (FAs)

i.e. has 3 or more admissions in the past 1 year

• Reduce unnecessary hospital bed days and emergency attendances 2016

Transitional Care Service

• Single-point-of-contact to coordinate the care plan of patients with complex care needs

• Support safe and coordinated transitions from the hospital to the community and home

2018

Community Health Teams

• Population health focus• Managing the pre-frail to frail

Transitional Care within the RHS Tripartite Framework for Care Coordination

The TTSH Community Health Team works closely with Community Partners, who will help the patient navigate the services in the community, and also establish GP & Primary Care

support for the patient.

Cri

sis

Fra

ilty

Dyin

g W

ell

We

llIl

lnes

s

FMC

GP

Polyclinics

PATIENT

Community Health Team

Community Partners

Primary Care

Community Health Team

ACTION CC

VH Health Manager

PACH

P1

P2

ACTION

CENTRAL ZONE DEMOGRAPHICS

Oldest Population of 17% aged 65y & Above (13% Nationally)

53% of Inpatients aged 65y & Above(29% Nationally)

Largest Population Catchment of 1.4M (26% of 5.54M)

Central, 65y &

Above, 17

Yishun, 65y &

Above, 10

Woodlands, 65y & Above, 8

% Population ≥65 Yrs

Central

Yishun

Woodlands

Why the Move Towards Population Health?

ROLE OF COMMUNITY HEALTHTo ensure and maintain the well-being of the Central Health resident population, keeping

them well in the community and minimizing healthcare resource utilization.

Ang Mo Kio

Bishan

SerangoonHougang

Geylang

Novena-Kallang-Rochor

Toa Payoh

NHG Central Zone

- Primary Care* - Community Partners*

*Note: Locality-Based

- Activated Residents*

3 Aspects of Well-Being

• Health• Social• Mental

Our Three-Pronged Strategy

• Service provision• Collaboration• Activation

The Community Health Framework (within Sub-Zones)

Hospital Community

Dis

cha

rges

ED

SOC

Inpatient

Comm. Care Prog.

Comm. Nursing/ H2H

COMMUNITY HEALTH TEAM

Value Stream Mapping and

Process Improvement

• SGA• CNS• CHPs• VWOs

Community-Based

• CHs• NHs• Hospices

Institution-Based

COMMUNITY PARTNERS

The Community Health Eco-System

CRISP

Empanelment

Primary Care Networks

• GPs• FMCs• Polyclinics

Primary Care

PRIMARY CARE PARTNERS

• CHA

Activated Residents

Project Care

Project Dignity

Programme IMPACT

Hands off means a change in primary provider in a Community

Of Providers

MY

Patient

OUR

Patient

Understand the needs of the current unenrolled; think of how

to meet these needs

“ENROLLED” Population

WHOLE Population

Centre is our “base”; but caredelivery can be anywhere

To understand the different ways of affecting the environment & its

occupants

CENTRE

Focused

COMMUNITY Focused

Shifting of focus:

From services provided by TTSH to how we can work together to meet all needs in a coordinated manner

Delivery of SPECIFIC Services

Meeting ALL Needs in

Integrative Ways

What We Hope to Be Different With Community Health

Building relationships and working with local partners across health care and social care domains to enable health engagement, care coordination and ageing-in-place.

Community Health Team

7 Place-based, multi-disciplinary* teams embedded in each zone*Comprising doctors, nurses, allied health professionals, pharmacists and medical social workers

Community Health Team

OBJECTIVE OF THE COMMUNITY HEALTH TEAMSTo build relationships and work with local partners across health care and social care domains to

enable health engagement, care coordination and ageing-in-place.

Delay Frailty Progression

Empowering Self-Management of Health

Issues

Management of Acute Medical

Conditions

Case Management

Primary focus of Community Health Teams

Service Provision• Risk assessments• Case management• Coaching, education, counselling• Promoting self-empowerment• Bridging interventions

Collaboration

• Case discussions• Co-management• Care transitions

Activation

• Co-creation of programmes• Co-learning of best practices• Create activated communities

Direct Service Provision

• Home visits

• Telephone reviews

• Site clinic reviews at Community Health Posts

Collaboration & Activation

• Development of interest-based programmes for residents

• Falls screening with partners

• Group education and coaching

• Training for partners

Building relationships and working with local partners across health care and social care domains to enable health engagement, care coordination and ageing-in-place.

Community Health Team

How Our Teams Work

Referral form

THANK YOU