Continuing and Community Care Department

We aim to improve collaboration between our hospital and the voluntary welfare organizations providing care.

Our mission is to provide accessible, seamless and individual-focused care to the vulnerable (eg. Patients with multiple co-morbidities and the disabled), using a multi-disciplinary approach in collaboration with community partners.

Our philosophy is to engage community partners and identify gaps in care from a patient’s point of view and close them by collaborating on new services.

We are currently focusing on the nearby vicinity, particularly Toa Payoh.

Our scope includes:

  • Collaboration with Community Hospitals 
    • Provision of consultancy services by Geriatricians
    • Working on Care Integration between restructured hospitals and community hospitals
    • Simplifying the workflows between hospitals
    • Collaboration with Nursing Homes
  • Management of patients at the end-of-life in the nursing homes 
    • Management of chronic disease issues in the nursing homes
    • Geriatric consultation in the nursing homes
  • Liaison with General Practitioners 
    • Providing training for general practitioners to manage geriatric syndromes in the community
  • Post Acute Care at Home (PACH) 
    • Provides time-limited multidisciplinary care for patients with complex needs, discharged from Tan Tock Seng Hospital
    • Includes medical assessments, nursing monitoring, caregiver training and support, and therapy services