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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

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.


A bright and sweltering Thursday morning greeted Community Nurse Katherine Lai Kai Yun and Occupational Therapist Lee Hengky as they arrived at Mdm Z’s home for their pre-arranged appointment.

The team had plans to check up on Mdm Z’s condition after her discharge from hospital, as well as on her functional status within her home environment. However, her son informed the team at the door that Mdm Z had gone to the nearby market; he had no idea when she would be back, and she had no mobile phone.

There was no question of saving it for another day; Katherine and Hengky immediately headed back downstairs to look for Mdm Z. No sign of her at the wet market as Katherine and Hengky split up to search. “On the bright side, I met her during my assessment while she was still warded so I know what she looks like,” said Katherine. A few minutes later, she approached someone sitting at the hawker centre with a smile: Mdm Z had been found.

The journey back to Mdm Z’s home took much longer than the brisk walk there, as Mdm Z’s knees were not in the best condition. Katherine and Hengky took the opportunity to observe their client’s gait and balance, and the way she used her shopping trolley as a walking aid. When Mdm Z took a break at the void deck, they spoke to her about the pain in her knees and asked if she was having any breathing discomfort. Eventually they reached her home, and the assessments continued as planned.

Serving Residents Across Central Singapore

Singapore’s Central Zone has a population that is ageing more rapidly than the rest of the country’s: 17% of the residents in the zone are aged 65 and above, compared to a national average of 12%. This means that many of our residents have complex care needs, from medical and nursing care requirements to social support.

TTSH’s multidisciplinary Community Health Teams comprise nurses, allied health professionals like occupational therapists and physiotherapists, pharmacists, medical social workers, and doctors. Each CHT 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.

The teams also work hand-in-hand with community partners, such as grassroots organisations, social services, and other healthcare providers. As experts in their own fields and having built ties within the community over the years, our partners are best placed to help us connect with residents, and collaboratively create a strong base of support for patients and residents.

Journeying With Patients From Hospital to Home

Despite the community focus of the CHTs, care actually begins within the four walls of the hospital. While the patient undergoes treatment with our inpatient teams, the CHT conducts an assessment to understand the patient’s post-discharge care needs. The CHT nurse in charge of the patient then begins to coordinate the services that the patient will need, such as home nursing services or social or financial assistance. In Mdm Z’s case, Katherine had arranged for Hengky to visit at the same time, so that he could provide suggestions on adapting her home environment such as grab bars in the bathrooms. Katherine also spoke with Mdm Z’s daughter about procuring a motorised scooter to help Mdm Z get around more safely.

Caring for Residents in the Central Zone

Not every resident requires admission to the hospital, and even if they do, some may not meet the requirements for the home visit plans. To ensure that residents are given the care they need, the team conducts weekly clinic sessions at locations frequented by residents, such as senior activity centres.


​After a leisurely breakfast, Mr Peh Chee Guan walks into the clinic and greets the clinic assistants. A short wait later, he enters the consultation room where Dr Eng Soo Kiang welcomes him with a smile and asks how the Peh family has been. After a quick chat about Mr Peh's health and medication, Dr Eng then begins the follow-up tests and check-ups that Mr Peh's chronic conditions require.

Dr Eng Soo Kiang is from Unity Family Medicine Clinic in Serangoon Central, and has been part of TTSH's Community Right Siting Programme (CRiSP) for all four years since the programme first started. Under the programme, stable chronic patients from TTSH Specialist Outpatient Clinics are appropriately reviewed and cared for at the primary care setting.

Mr Peh has been seeing Dr Eng since 2015, when he was discharged from TTSH's cardiovascular clinic in August that year. He noted that TTSH clinic visits could take up to three hours in the past, but his regular appointments with Dr Eng take no longer than an hour each time, and the clinic is much closer to his house.

He added that he actually felt reassured when his specialist discharged him for follow-up in primary care, as this was a signal that his condition was stable and improved. Mr Peh had even begun making the effort to lead a healthier lifestyle by jogging regularly.

As for Dr Eng, he feels that the GP community receives strong support from specialists through such partnerships. They feel involved as they are incorporated into the workflow of managing patients' care.

He added: "I hope that through these partnerships such as CRiSP, patients realise that their condition has improved and stabilized to a point that they no longer require specialist visits. Eventually, all of us healthcare providers hope for patients to become 'activated' to take care of their own health as their conditions improve. Patients can be self-motivated to lead healthier lifestyles, quit bad habits such as smoking, and be recognised for their efforts to make lifestyle changes."

Under CRiSP, primary care partners can manage patients with 30 common chronic conditions such as diabetes, hypertension and ischaemic heart diseases. TTSH officially launched its partnership with primary care partners on 22 September 2018.

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2019/06/19
Last Updated on