Communities of Care Approach: Developing a Place-based Model of Care and Building Partnerships in the Communities in Central Singapore

Health and social care providers work in silo, making care fragmented

Establish a network of partners offering varied services, facilitated by identifying a committed anchor NGO partner to coordinate the network to deliver needs-stratified services for residents in a defined neighbourhood

TTSH plays a developmental role in building the network, establishing the terms of engagement to organise partners for coordinated health-social care delivery, which may be handed over to an anchor organisation in the stable state

Partners provide services relevant to a range of biopsychosocial needs, such as resident outreach activities⁴, preventive care services, healthy lifestyle programmes, opportunities for socialisation, befriender services, chronic disease care, transitional care

Formalise relationships within the network of partners to ensure delivery of care aligned with objectives

Partners sign agreements to formalise agreed objectives, organisational responsibility and services to be delivered, and outcomes of collaborations

Lack of consolidated and up-to date information on services available to service providers within a neighbourhood

Establish a repository of various services across the health-social continuum available within a neighbourhood for easy reference by providers

Each CoC collates a repository (menu) of services and programmes (addressing physical, financial, social, emotional, intellectual, vocational needs) within the neighbourhood, stratified by “generic needs” and “specific health needs”

Partners access a common platform consolidating up-to-date information on programmes across all providers, including location and eligibility criteria, to facilitate referrals of residents to relevant programmes

At-risk individuals remain unknown to the health-social system

Establish neighbourhood-based registries with standardised information for access by different partners and to track health of each HDB block

One Resident Health Record is leveraged on to keep track of social and health data of residents

Identify “unknown” and “vulnerable” populations previously unknown to partners for needs assessment

Joint, targeted outreach to “unknown” and “vulnerable” residents is conducted through community health screening and door-to-door outreach

Health and social care providers conduct independent needs assessments; no provider has a complete picture of the biopsychosocial health status of residents living in neighbourhood

Perform biopsychosocial needs assessment as a holistic assessment of residents’ current and potential problems

Common needs assessment tools based on interRAI, such as Community Screener Tool (CST) used by AACs and the Preventive Health Visit (PHV) surveys used by SGO, have been aligned with similar screening items and post-screening follow-up workflows

Care plans are co-developed using the terminology based on the Omaha System through regular case discussion platforms and shared across partners using a standardised Combined Case Discussion template

Care is episodic and often not planned or carried out over time across service providers

Identify services in the health-social care continuum to meet residents’ assessed biopsychosocial needs and ensure affordable access to recommended services or programmes across population segments

Partners develop collective care plans based on assessed multi-dimensional needs and preferences with a long-term view

Partners take ownership of care delivery for each case and ensure delivery of intended care plan in a coordinated manner, with agility to tweak care plans as needs change

Lack of communication and coordination across health and social care providers

Co-develop structured protocols to plan and coordinate needed care across partners, time and settings, especially for residents with complex needs

Standardised workflows for referrals and documentation are established amongst partners, overseen by the anchor organisation

Partners hold regular case discussions and facilitate referrals based on needs

Create an infrastructure to exchange information for timely and secure information flow

Partners are notified of residents’ hospital admissions and discharges via Central Health Linkup (facilitated by TTSH’s Healthcare Intelligence (HI) system)

Partners communicate and update on care plans and interventions via email, TigerConnect (a secure and direct messaging platform) and case discussions

Resident’s values and preferences are less considered in their care plans; lack of provider-resident relationship based on mutual responsibility and trust

Establish a centralised touchpoint within the neighbourhood for residents to seek information or address any arising needs

The anchor organisation provides a centralised and familiar access point for residents

Take into account residents’ values, needs, and preferences in design of care plans

Foster relationship-based care with an orientation to whole person care

Establish peer support networks to facilitate social connection to support sustaining good health behaviours.

The anchor organisation advocates on behalf of the resident and family in health activation, case discussions and care planning

CHT introduced ‘What Matters to You (WMTY)’ conversations⁵ to enable a shift towards relationship-based care; this was also extensively adopted by SGOs as an engagement framework

Health coaches guide residents in addressing identified health goals

Health coaches work with anchor organisations to provide group-based programmes to promote peer learning and social support amongst residents

Skills-based programmes are conducted to engage residents and increase health literacy and translation of knowledge to self-care

Embed link workers in the neighbourhood to facilitate residents’ access to programmes and services

Health coaches⁶ and primary care coordinators (PCC)⁷ link residents with relevant services and resources based on their health plans and goals

Health coaches also nudge and monitor residents for actualisation of the recommended health plans