New Care Models to Keep Residents in Ang Mo Kio Healthier
18 March 2022 – In a decisive step towards empowering health in the community, Tan Tock Seng Hospital (TTSH) officially opened the
TTSH Ang Mo Kio Specialist Centre (AMKSC) today. The ceremony was officiated by Prime Minister Lee Hsien Loong.
Following the launch of Healthier SG by the Ministry of Health last week, TTSH showcased new models of care for residents in Ang Mo Kio at its two-storey AMKSC. These care models are part of the hospital’s three-pronged Central Health strategy, which aims to strengthen care beyond its hospital walls and nurture healthier communities in Central Singapore.
First Strategy – Bring Care Closer to Residents
To bring in-demand specialist care out of the hospital into the community, TTSH has been innovating its services to make them more accessible, sustainable and appropriate to be delivered consistently in the community. Key services at three of its clinics at the main hospital have been redesigned and brought into AMKSC as a result.
Trans-disciplinary Diabetes Care Management Model – Patients with diabetes, who would normally need multiple visits to various healthcare professionals at the main hospital, can now be seen by specially trained Clinical Diabetes Educators (CDEs) at AMKSC. These CDEs have received special cross-training to holistically carry out various aspects of diabetes care and patient education. This change makes it possible for patients to better manage their condition closer to their home with fewer visits to the hospital; from the previous eight or more hospital visits a year previously, a patient may now only require three to five visits at AMKSC. Mdm Low Hong Eng has been cared for by the TTSH diabetes team since 2007. In 2020, she was onboarded to this new care model at AMKSC. She said: “Ang Mo Kio Specialist Centre is closer to my home in Hougang, which makes appointments easier to get to. The CDEs at AMKSC have been very helpful in advising me on all aspects of managing my diabetes, including advice on new monitoring devices, and relevant nutrition. I am controlling my blood sugar levels much better now.”
Optometrist-led Community Eye Care Model – Demand for specialist eye care has been increasing with an ageing population, resulting in long wait times for hospital appointments. TTSH has upskilled their team of optometrists who can manage chronic eye conditions such as blurring of vision, redness and suspected glaucoma, siting them at Community Eye Clinics at AMKSC and elsewhere. The team also conducts visual acuity and eye diagnostics tests, and follows up on consultation with specialists at the main hospital when necessary. This model of care has enabled Ang Mo Kio residents to access faster eye appointments and nearer care.
Audiologist-led Community Hearing Evaluation Model – Hearing is another function which decreases with age. With more mass health screening in the community to uncover hidden health issues in the elderly, there is a need to follow up on these suspect issues with faster and more accurate hearing diagnostics. TTSH’s team of audiologists provide both specialist and basic hearing examinations and services, as well as hearing aid interventions at AMKSC. Residents diagnosed with more complex hearing conditions will be referred to specialists at the main hospital. This coordinated approach has allowed more residents to be followed up after the initial community screening and catch potentially serious hearing-related issues earlier.
To bring testing to even more people more quickly, AMKSC has successfully trialled and will be implementing a portable audiometry system without the need for a soundproof setting. This allows more residents in different settings such as nursing homes or in primary care settings to gain access to testing, enabling faster detection and intervention to hearing issues.
Second Strategy – Partner GPs & Polyclinics to Anchor Care for Residents
Besides locating the above specialist care at AMKSC, TTSH is also partnering GPs and polyclinics in the co-management of residents’ health. Its first step is to enable direct referrals from GPs to specialist diagnostics, therapy and procedures offered at AMKSC.
Traditionally, these services such as diabetes support services of eye imaging and foot screening are only offered in hospital settings or via a referral by hospital specialists. Working closely with GPs, the teams at AMKSC will keep referring doctors updated on the patients’ progress before referring them back for continued care and overall health.
Of noteworthy mention is TTSH’s extension of its allied health services and basic endoscopic procedures at AMKSC to GPs. Work is ongoing to strengthen partnerships with GPs to better support residents’ health and care throughout their lives.
Integrated Musculoskeletal (MSK) Therapy Services – Many musculoskeletal conditions can be resolved with physiotherapy or occupational therapy and do not necessarily require surgery. Prior to the new Integrated Musculoskeletal (iMSK) shared care model at AMKSC, patients had to see a specialist in the hospital before being referred to these allied health services. Now, patients with specific conditions such as carpal tunnel syndrome and osteoarthritis knee pain can be referred directly by their GP to therapists with advanced practice skills at AMKSC. Referring GPs are also kept closely updated on their patients’ therapy progression so that they can make better overall care plans for their patients.
Dr Lim Kim Show, a GP at Life Family Clinic in Ang Mo Kio, noted that his patients have seen the benefits of the iMSK care model. “Getting early intervention for such conditions makes a big difference in patients’ recovery. This direct referral process can cut down waiting time by more than a month, which means they get treatment that much faster,” he said. “Getting progress updates from the TTSH team also helps us to manage patients’ overall health better. Having these workflows in place allows us to deliver better care to our patients together.
Day Surgery Centre with direct access by GPs for basic endoscopic procedures – To make it easier for residents to undergo basic diagnostic endoscopic procedures such as gastroscopy, a day surgery centre with operating suites and a recovery room for observation has been set up at level 2 of AMKSC. TTSH is also enabling GPs to make direct referrals to the endoscopy team at AMKSC, who would keep them updated on their patients’ progress for continuing care post-procedure. Such close partnerships in care can help the GPs better manage the overall health of residents.
Third Strategy – Integrate Health and Social Care Support
Besides GPs and polyclinics, TTSH also works with other health and social care partners in the neighbourhoods to enable better health for residents. These collaborations help ensure a more holistic ecosystem to identify and address health needs of residents and to activate them to stay healthy. AMKSC’s location right in the heart of Ang Mo Kio will facilitate better understanding and closer collaborations amongst the partners. Already, there are exciting plans with the Agency for Integrated Care’s (AIC) outreach arm, the Silver Generation Office (SGO).
TTSH-SGO Health & Social Care Partnership – The co-location of TTSH’s Community Health Team (CHT) and SGO within AMKSC enables active coordination and collaboration. SGO reaches out to residents in the area and refers relevant cases to TTSH through its CHTs, and this co-location allows both teams to work seamlessly together to identify residents in need, plan community-based programmes, and coordinate health and social care plans with other partners in the community.
SGO and TTSH also co-developed a training module for AIC staff and SGO’s Silver Generation Ambassadors to carry out meaningful conversations and identify what matters to residents during their outreach efforts. They can then direct residents to join suitable health and lifestyle programmes, or link them up with GPs or TTSH’s CHT for more targeted care interventions. Through this partnership, SGO and TTSH aim to reach out to more residents who may have unmet health and social needs.
“As AIC’s outreach arm, the role of SGO is to engage seniors in the community to share about the support available, and to connect them to relevant schemes and services that they may require. Through this partnership with TTSH and its Community Health Team, our Ambassadors can be better equipped to support seniors with their needs, continuing our vision of enabling them to live well and age gracefully. Together, we can deliver more targeted and coordinated care to the residents we serve,” said Mr Tan Kwang Cheak, Chief Executive Officer of AIC.
AMKSC’s models of care are in tandem with the national mission to ensuring that the population that we serve is cared for closer to home, and kept healthy and happy within the community. Adjunct Professor Eugene Fidelis Soh, Chief Executive Officer of TTSH & Central Health, said: “With Healthier SG, we are bringing care closer to our residents, working alongside our GPs and Community Partners in the community. The hospitals of the future are no longer just brick and mortar, but one without walls.”