Enhanced community-based patient care experience through the Flow-Hold-link Care model

Background: Singapore’s rapidly ageing population projected to reach 25% aged 65 and above by 2030 and a rising chronic disease burden threaten the sustainability of hospital-centric care. In response, there is an urgent need for integrated, community-based approaches that empower residents to manage their health and improve outcomes across the care continuum.

 

Approach: As part of the national Healthier SG movement, SingHealth has transformed patient experience through initiatives that bring care closer to home and empower residents in their health journey. To help residents Keep Well, Get Well and Live Well, SingHealth has adopted the Flow-Hold-Link Care model.

This operational model was co-designed with stakeholders across healthcare, social, and community sectors, and is structured as follows:

• Flow: Ensures seamless transitions for patients requiring hospital care, while enabling timely right-siting back to the community.
• Hold: Supports residents to remain in their communities through place-based teams, Community Nurses, and Wellbeing Coordinators (WBCs), delivering tailored preventive and chronic care.
• Link: Integrates healthcare providers, community partners, and social services to deliver holistic, person-centred care, leveraging digital health solutions and shared care protocols.

Key interventions include:

• HealthUP!: A preventive health movement supporting screenings, vaccinations, and lifestyle changes, in collaboration with community partners and enabled by technology.
• SingHealth Place-Based Services: Empower Community Care team also known as SingHealth Healthier SG team₁ to manage complex conditions locally with shared protocols and direct access to specialists.

 

Results: The Flow-Hold-Link model has delivered measurable improvements in patient experience and outcomes:

• Over 170,500 residents’ profiles onboarded via HealthUP! Dasboard @ Health Buddy
• Over 32,000 residents supported by SingHealth Healthier SG Team¹
• More than 21 Government agencies, social and community partners engaged
• Enhanced support for seniors and chronic disease patients via telecare and home-based services.

 

Implications: This model demonstrates that integrated, community-based approaches can transform patient experience and health outcomes in rapidly ageing societies. Key learnings include the importance of strong partnerships, digital innovation, and tailoring services to local needs. These insights are relevant for international delegates seeking scalable models for population health management and sustainable healthcare transformation.

 

Note:

1.SingHealth Healthier SG Team: A multidisciplinary team comprises of Community Nurses and Wellbeing Coordinators (WBCs), who works closely with Community Partners, and Primary Care Providers to provide place-based integrated care to our residents and empower them to achieve their health goals.