Enhancing Cross-Organisational Care Coordination through SingHealth Residents’ and Partners’ Relationship Management (RPRM) System

Background: In the evolving landscape of Healthier SG, integrated care teams face increasing complexity in managing referrals and coordinating care across institutions. To address these challenges, SingHealth developed the Residents’ and Partners’ Relationship Management (RPRM) system – a cluster-wide digital platform designed to streamline referral workflows, case stratification, assignment and appointment scheduling with the following objectives.

 

1. Develop a standardised work processes for SingHealth place-based community care teams known as Healthier SG Teams
2. Facilitate seamless referral management by eliminating the manual tracking of referrals via Excel and individual care staff emailing referrers on referral status
3. Streamline referral management and appointment scheduling into a single platform
4. Devise a harmonised stratification framework to aid in case assignment and dashboards to monitor referrals received
5. Improve management of confidential patient information via a secured platform

 

Approach: An agile approach is adopted to manage the development of referral management module in RPRM, necessitating strong collaboration between IT project managers, user project managers and users from Changi General Hospital, Singapore General Hospital, Sengkang General Hospital and SingHealth HQ. User project managers closely engage the key institution stakeholders via a User Champion Workgroup to analyse workflow processes and propose harmonized cluster solutions, which are translated into system designs and undergo iterative cycles of development, testing, and feedback to ensure continuous improvement and alignment with the needs of key users like Community Nurses and Wellbeing Coordinators WBCs).

 

During deployment, user project managers oversee rigorous testing and escalate any issues to IT project managers for timely resolution. Post-release, the user project team supports users through mass training, on-site assistance, and troubleshooting via dedicated Teams Channel, ensuring smooth adoption of the system.

 

 

Results: Between 2023 to 2025, a total of 3 RPRM minimum viable products (MVPs) were launched. More than 200 Community Nurses, Wellbeing Coordinators, Precinct Leads, and admin staff have been trained and onboarded to RPRM. With the launch of harmonised cluster referral form via FormSG, institutions had ceased the manual referral management via Excel. All referrals received are extracted from FormSG and uploaded into RPRM for tracking. A cluster stratification framework and round robin algorithm were devised to auto-assign referrals to appropriate care staff.

 

Closed referral feedback loop to referrers via email is auto triggered after referral status is updated in RPRM. To streamline operational processes, appointment scheduling system has been integrated with RPRM to streamline appointment scheduling process. Operational dashboards are developed to monitor the referral status and turnaround time. Integrated system audit features are also built for data security.

 

Implications: RRPM improves work efficiency, aids in management reporting and data analyses, promotes care continuity and enhances security in handling patient data. It also strengthens system-wide governance by standardising processes and facilitating collaborations in the community.