Previously known as the Transitional Care Team, the Community Health Team (CHT) has seen its scope and responsibilities expanded since its formation in March 2018, evolving towards place-based community care. In the three months that followed, the team served more than 365 residents.
The multi-disciplinary team comprises medical doctors, nurses, allied health professionals, medical social workers and pharmacists. They collaborate with community partners to run clinic sessions at various locations throughout the Central Zone.
The CHT’s primary function is to build relationships with healthcare and social care partners, enable health engagement, care coordination, and ageing-in-place. Referred or walk-in residents are reviewed and appropriate interventions (e.g. medication reconciliation, assessments and education on fall risk, health education etc.) are undertaken.
Should a resident be confused about his/her medication, for example, a CHT nurse would work with the team’s pharmacist to obtain the latest medication list, and provide education on proper pillbox packing to the resident or his/her caregiver. The team links up with relevant community partners, including neighbourhood General Practitioners (GPs), for continued follow-up on the issues identified.
"By situating the CHT in neighbourhood areas, we are able to reach out to the residents and empower them for better self-care alongside community partners, including GPs.”
Residents have generally been receptive to the initiative, with one remarking that he felt reassured that his GP could link up with hospitals and tap on community resources through the CHT.
Team members have also seen the benefits first-hand, developing links with residents who might otherwise resist medical care. They see themselves as part of the healthcare puzzle, collaborating with community partners, including GPs, and linking them up with the hospital to provide more integrated care and empower residents – a part of a holistic approach that is the future of healthcare.