Targeting Health Determinants Through Cross-Sector Partnership: Singapore's Integrated Care "HOlistic Management & Enablement" (HOME) Model

Background: Low-income families with young children often face challenges in health, education, and social wellbeing, yet struggle to navigate existing services which are fragmented across sectors. Recognising these gaps, Project HOME was launched as a 2.5-year pilot programme in 2023 to deliver integrated, family-centred support in Singapore's Northeast region. This Ministry of Health-funded initiative represents a cross-sector partnership involving Sengkang General Hospital, KK Women's and Children's Hospital, Family Service Centre Allkin Singapore, and NTUC First Campus preschool.

 

The programme operates across three domains: providing screening and support for children's development and school readiness; promoting healthcare adherence including routine vaccinations, developmental screenings, and health assessments whilst encouraging appropriate health-seeking behaviours and improved dietary practices; and strengthening family functioning self-efficacy whilst facilitating service linkages.

 

Approach: This study employed a mixed-methods longitudinal evaluation design, combining quantitative surveys with qualitative interviews. The miniFAST tool assessed family functioning and strength. Data collection occurred at baseline, 6 months, and 12 months, measuring attitudes, knowledge, behaviours, and service utilisation.

 

Families with children aged 2 months to 6 years, household incomes below SGD 4,500, and residing in Punggol or Sengkang were referred by participating organisations. Children were stratified into three risk tiers based on six criteria: school attendance, medical conditions, growth/nutrition, immunisation adherence, routine visit compliance, and behavioural/developmental issues.

 

 

 

Results: Total enrolment comprised 226 children from 142 families. Approximately 52% had 1-2 children, 20% had 3 children, and 17% had 4 or more. About 67% earned between $2,501-$4,500. High-risk (Tier 3) classifications decreased from 63% at baseline to 40% after one year.

Caregivers demonstrated significant improvements (p < 0.01) in knowledge regarding screen time and sleep habits, alongside enhanced ability to manage children's screen time, sleep hygiene, healthy eating and physical activity. Screen time decreased on both weekdays and weekends, though caregivers found behaviour changes for diet, sleep and physical activity changes more challenging.

 

Healthcare outcomes improved markedly: routine developmental visit adherence increased from 58% to 74%, vaccination rates rose from 94% to 97%, well-managed health cases doubled (64% to 80%), and poorly managed developmental issues halved (20% to 10%). MiniFAST data revealed statistically significant improvements (p < 0.01) in family resiliency, resourcefulness, and relationships.

 

However, 20-30% attrition occurred, with families having complex needs more likely to disengage due to perceived irrelevance. Qualitative interviews highlighted appreciation for consistent home-based support whilst identifying engagement challenges for complex-needs families.

 

Implications: Results: demonstrated clear benefits in children's screen time behaviours, healthcare navigation, utilisation improvements, family strengthening, and service model value. Key gaps persist in dietary, sleep, and physical activity behaviour change, plus attrition among complex-needs families. These insights inform future maternal and child healthcare delivery by Community Nursing within SingHealth Regional Healthcare Cluster.