We aim to improve collaboration between our hospital and the voluntary welfare organizations providing care.
Our mission is to provide accessible, seamless and individual-focused care to the vulnerable (eg. Patients with multiple co-morbidities and the disabled), using a multi-disciplinary approach in collaboration with community partners.
Our philosophy is to engage community partners and identify gaps in care from a patient’s point of view and close them by collaborating on new services.
We are currently focusing on the nearby vicinity, particularly Toa Payoh.
Our scope includes:
- Collaboration with Community Hospitals
- Provision of consultancy services by Geriatricians
- Working on Care Integration between restructured hospitals and community hospitals
- Simplifying the workflows between hospitals
- Collaboration with Nursing Homes
- Management of patients at the end-of-life in the nursing homes
- Management of chronic disease issues in the nursing homes
- Geriatric consultation in the nursing homes
- Liaison with General Practitioners
- Providing training for general practitioners to manage geriatric syndromes in the community
- Post Acute Care at Home (PACH)
- Provides time-limited multidisciplinary care for patients with complex needs, discharged from Tan Tock Seng Hospital
- Includes medical assessments, nursing monitoring, caregiver training and support, and therapy services
You may want to read about
Continuing and Community Care Specialists
Some people are not afraid to talk about dying (external link)
他们选在疗养院 平静走完人生路
