Beyond Boundaries: A Regional Approach to Mental Healthcare Delivery

Background: Healthcare fragmentation remains a significant challenge, particularly when addressing the interconnected nature of physical and mental health needs. In addition, healthcare models often operate in institutional silos. A baseline survey of community partners revealed gaps: On a scale of 1 to 5, community mental health providers scored 3.18 for knowing who to contact to escalate concerns to psychiatry departments, 2.88 for feeling adequately supported when co-managing cases, and 3.11 for feeling connected to the network of mental health resources and partners.

 

The Assessment and Shared Care Team (ASCAT) traditionally operates via teams from each hospital. These Psychiatrist-led multidisciplinary teams build capability of primary and community care partners to manage clients with mild to moderate mental health conditions. NHG Health, the Health Manager for Singapore's Central-North Region, recognised an opportunity to address broader healthcare fragmentation by restructuring ASCAT as a regional initiative spanning multiple healthcare institutions across the region.

 

Approach: The One NHG Health ASCAT, a regional model launched in April 2025, adopts a population health perspective that addresses broader healthcare ecosystem needs and fragmentation across the Central-North region.

Key innovations include: (1) leveraging collective insights and strengths across institutions through curated training materials informed by learning needs analysis, post-training surveys, and partner engagement; (2) integrating community health teams into the ASCAT training ecosystem to build connections with other partners and increase their capability to manage residents with both physical and mental health needs; (3) standardised referral and care protocols to ensure quality and timely access to tertiary care services, including understanding care pathways between ecosystem partners; and (4) a regional structure enabling multiple institutions to collaborate on solving system-wide problems that could not be addressed independently, creating opportunities for collective problem-solving and resource sharing.

 

Results: In its first quarter of operation, ASCAT delivered 321 training hours, established paired referral workflows between primary care clinics and tertiary services, and established links with partners. While coordination occurs at the regional level, service delivery remains localised, ensuring community partners continue working with familiar institutions while accessing enhanced regional resources and support.

 

Early implementation insights include: (1) responsive training programme design with systematic feedback loops is more effective than one-size-fits-all approaches; (2) standardisation reduces decision-making burden on providers, guides appropriate escalation, and prevents patients from falling through care gaps without stifling flexibility; (3) relationship building and engagement with all stakeholders, including funders, internal and external partners, are essential to align priorities for long-term impact; and (4) system-level approaches, while requiring extended consensus-building periods, enable identification and resolution of care gaps that institution-specific models cannot address.

 

Implications: This regional cluster model demonstrates how healthcare programmes can be restructured to maximise health and social integration across care settings. By adopting a population health perspective that transcends individual programme boundaries, this approach creates opportunities for comprehensive system-wide improvements addressing healthcare fragmentation. The model emphasises regular stakeholder engagement, iterative programme refinement, and building support ecosystems, offering a replicable approach for health systems seeking to strengthen community-based care coordination while building local capability to manage mental health conditions.