Patient Guide

Community Health Programmes

Collaborations with NHs Project Care

In September 2009, TTSH started on Project CARE with funding from MOH. Project CARE deploys three doctors, seven nurses and a medical social worker to the nursing homes daily, where they assess nursing home residents based on the severity of their conditions and risk of mortality and treat the residents accordingly. They also meet residents and their families to discuss an Advance Care Plan. This helps nursing home residents remain in dignity at their preferred place of death when death is unavoidable, in accordance with the resident's wishes. Through this project, TTSH works with seven nursing homes:

  • Lions Home for the Elders, Toa Payoh
  • Ling Kwang Home For Senior Citizens
  • Ren Ci Long-Term Care
  • Ren Ci Nursing Home
  • Society for the Aged Sick
  • Saint Theresa's Home
  • Singapore Christian Home currently.

Medical Consultancy Services

The Consultants from department of Continuing and Community Care also provides medical consultancy services to nursing homes and community hospitals. By doing so, the department hopes to augment the medical services that are already available in these institutions, and hopefully reduce unnecessary utilization of Specialist Outpatient clinics or admission.

We provide medical consultancy services to three nursing homes, namely, St Theresa’s Home, Thong Teck Home for the Senior Citizens, and Ling Kwang Home for Senior Citizens, and three community hospitals, namely, Ren Ci Community Hospital, Kwong Wai Shiu Hospital, and Ang Mo Kio – Thye Hua Kwan Hospital.

In addition to provision of visiting consultancy services to Ren Ci Community Hospital, staff are seconded on a part-time basis to the institution. This has been found to meet the needs of the institution better, as there is a stable deployment of staff, and seconded staff are also able to address some of the developmental concerns of the institution.

Post Acute Care at Home (PACH)

Post Acute Care at Home is a post-discharge supportive care service, formed by a team of doctors, nurses, therapists and medical social workers. The PACH team aims to stabilise and rehabilitate patients with sub-acute phase of the illness at their home, as well as to provide appropriate home care support to promote better self care. PACH also aims to help the caregivers to be competent in managing the homebound patient at home so as to reduce the need for institutionalized care.

The doctor and nurse will assess referred patients at their home in terms of medical, psychological, social and rehabilitation needs. A multidisciplinary plan is drawn up, and the management plan will be coordinated by the nurses and be agreed upon by team during multidisciplinary meeting.

The targeted period of care is for about three months. Following that, provision of treatment of ongoing medical condition and treatment of any functional impairment may be in collaboration with community healthcare service providers.

Transitional care (tc) programme

(formerly known as the Virtual Hospital (VH) and the Aged Care TransitION (ACTION) programmes)

The TC programme was started in July 2016 to ensure that every patient with complex care needs has a single point of contact to coordinate his care plan and support a safe, coordinated & timely transition from the hospital to the community and home. Patients enrolled into the TC programme usually suffer from multiple chronic conditions, with limited social support, and require close monitoring for some time to help them cope with and in turn, actively manage their illnesses at home. Patients may also be frequent admitters who seek care at the hospital’s Emergency Department (ED) for problems that can potentially be managed at home.

Enrolled patients are assigned a TC Specialist who will be their single point of contact. The TC Specialists, supported by a team of clinicians, nurses, allied health professionals and administrators, provide in-hospital care coordination and follow-up with patients post-discharge through telephonic reviews and home visits.

Together with the NHG Neighbours Care Coordinators, the TC team also collaborates with a network of community and primary care partners (e.g. GPs, Polyclinics & FMCs) to co-manage patients where suitable and assist patients to get help in navigating the various services in the community.

For more information about the TC programme, please call 6359 6490.

Stepping Out Into Active Life

‘Stepping Out into active life’ is a comprehensive one-year programme that aims to reduce the risks of falls among the seniors in the community by equipping them with the skills needed for an independent and healthier life.

To achieve this, the healthcare professional (consisting of doctors, nurses, physiotherapists, occupational therapists, medical social worker and volunteers) work with partners such as Voluntary Welfare Organisations (i.e. Family Service Centres and Seniors Activity Centres) located in the catchment area of TTSH. All participants will first be assessed for their risk for falls, hearing and vision functions, general fitness, balance and walking ability. The occupational therapists will also conduct home assessments to identify any fall hazards and recommend the necessary home modifications. Find out more here.

Engage In Life (EIL)

EIL focuses on empowering those 50 years old and above with the knowledge and skills in making small changes in their daily routines that enable them to live a happier, healthier and longer life. The end goal is to see each elderly take up the responsibility to plan, carry out and follow up on changes to prevent ill health, improve quality of life and live life to the fullest. Find out more here.

Who should attend?

  • 50 years old & above
  • Desire to live life to the fullest
  • Keen interest in empowering your friends & love ones in living a healthy and independent life

What does the course cover?

Different topics will be discussed each week. Examples of the topics covered are:

  • Successful Ageing
  • Osteoporosis / Home Safety
  • Social Networking
  • Healthy Eating
  • Physical Activity

Be Your Health Manager

(formerly known as the Chronic Disease Self-Management Programme (CDSMP))

Many people with chronic illnesses suffer fatigue, loss of energy, pain or breathing difficulties. Sleeping problems and depression are common, combined with concerns for the future. A healthy way to live with chronic illness is to work at overcoming the symptoms. Be Your Health Manager is a programme developed by the School of Medicine at Stanford University aimed to give people the confidence and motivation they need to manage the challenges of living with chronic illnesses. Find out more here.

METT (Maintenance Exercise Therapy Team)

METT is a collaborative project between TTSH Occupational Therapy, Physiotherapy, Rehabilitation departments and MCYS. The main aim of METT was to improve the programs in the Day Care Centres (DCC) and facilitate systematic upgrading of skills of staff in the community.

There are 4 phases to the program:

  1. Evaluate DCCs
  2. Develop manual (based on Workforce Skills Qualification - WSQ standards)
  3. Train DCC staff + competency assessment (based on WSQ standards)
  4. Re evaluate DCCs every 6 months for 2 years