A cheery smile greeted Community Nurses Su Qingfeng and Lim Yi Jia as Mdm Chaw walked slowly into one of their community clinic sessions at Ang Mo Kio’s COMNET Senior Activity Centre. To start with, they checked her physical condition, blood pressure and blood sugar levels, then taught her the right way to measure her blood pressure on her home machine.
Mdm Chaw had several questions about the medication she’s been taking for her chronic conditions so the nurses advised her accordingly, as well as checked on her gait and balance. As they chatted, Mdm Chaw asked, “Why is my walking stick wobbly? Is it stable?” The nurses assured her that the walking aid was designed to tilt with her body weight.
Once a week, nurses from TTSH’s Community Health Teams conduct these sessions for residents within Central Singapore, with the aim of helping residents manage their chronic conditions better. Residents with potential medical issues, who had previously not been known to the health system prior to the sessions, could also be followed up on.
These multidisciplinary teams comprise nurses, allied health professionals like occupational therapists and physiotherapists, pharmacists, medical social workers, and doctors. Each team is stationed within one of seven subzones in TTSH’s care range, and by creating a single team and point of contact, we can deliver holistic community-based care to our patients.
Working with partners located within the neighbourhood was the best way to connect directly with residents in the respective communities, as their centres host these residents on a near-daily basis and the staff often have greater insights on residents’ needs and lifestyles. Collaboratively, we create a strong base of support for patients and residents.