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Home > Central Health > Central Health Stories > Embarking on Our Population Health Journey

 By Tan Tock Seng Hospital

With an ageing population where our residents spend ten years of their lives in ill health, Singapore is embarking on its population health journey to build a sustainable care model to address these healthcare challenges. Population health, which looks at the health outcomes of a group of individuals, including the distribution of such outcomes within the group, is the cornerstone that will guide us and our partners as we care for our residents.

NHG’s ACO-ICO Framework
To achieve our population health goals, TTSH formed the Division for Central Health in 2018 to foster closer collaborations with community care partners in order to anchor care in the community and build a supportive environment for healthy lifestyles and ageing in place since 2018. In 2021, National Healthcare Group (NHG) set up an Accountable Care Organisation-Integrated Care Organisations (ACO-ICOs) structure. As an ACO, NHG allocates resources and leverages healthcare financing models to deliver the envisioned health outcomes. Within NHG, Central Health is one of the ICOs that will work with like-minded partners from primary care, community health and social care providers, and agencies like AIC and HPB to plan and provide care within Central Zone.

Population Profiling
To better support us in our care delivery, we first need to understand the population we serve. Compared to the national average, the central zone has a more elderly population, a higher proportion of residents living in HDB properties and a lower median monthly household income. Beyond sociodemographic factors, we also profile care utilisation patterns of the residents which have helped us better design our care models. For instance, TTSH is exploring enhancing stroke care delivery by harnessing data on stroke readmissions based on geographical distribution to identify potential service providers to partner and serve these patients. Through data analytics and insights, we can better understand our resident population’s needs and design suitable care interventions.

Overview of Central Zone Population

Relationship-Based and Place-Based Care Models
At the recent COS debate on 9 March, Minister for Health announced MOH’s plans to embark on a national Healthier SG strategy where every resident is encouraged to enroll with a primary care doctor. With the newly announced National Primary Care Enrolment Programme, our residents can journey with their trusted primary care providers to develop care plans catered to their needs. The primary care providers will in turn be part of Communities of Care in each neighbourhood to provide our residents a network of health and social care providers ready to support their needs.

Empowering Residents and Activating the Community
The key to success in our population health journey is an activated community where residents are empowered to manage their own health, and in doing so, are better able to care for their loved ones and others in the community. We are setting up the Central Health CLUB (Communities Living in Ur Block) as a platform for all residents living in Central Singapore to gain access to shared health resources and programmes, activate and sustain their health through goal setting and tracking, and contribute to a better neighbourhood through volunteering and community-building opportunities. Residents who join the Central Health Club will receive support from link workers, who will help to pace with and connect residents to programmes, groups and services that meet their health and social needs.

We are excited to be part of the remodelling of our healthcare ecosystem, and look forward to journeying with our residents and partners towards shaping happy, healthier communities in the Central Zone.

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