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Be Supported

Ageing-In-Place Community Care Teams

Residents with inadequate support at home and in the community may fall into a downward spiral of repeat hospital visits after a health crisis.

The Ageing-In-Place Community Care Teams (AIP-CCT) are nurse-led teams supported by multi-disciplinary healthcare professionals. These teams visit patients with progressive or life-limiting conditions in their homes and within community settings. The teams comprise nurses, doctors, therapists, pharmacists, medical social workers and healthcare assistants.

With the help of a spectrum of home healthcare services, patients can receive care and support in familiar surroundings. We support patients and caregivers to manage their conditions and reduce frequent visits to the hospital.

Our Suite of Services

  • Hospital-to-home services to aid the transition from hospital to community for patients at risk of hospital re-admission.
  • Early supported discharges with home rehabilitation to patients requiring active rehabilitation, as an alternative to a community hospital stay.
  • A discharge to assess pathway which allows medically-stable patients from the A&E or Extended Diagnostic Treatment Unit (EDTU) to return home for functional or psycho-social assessments.
  • Home palliative care services to relieve end-of-life patients’ symptoms and improve their quality of life.
  • Ageing-in-Place Medical Home (AIP-MH): A service mainly for patients with stabilised acute or subacute medical problems. It includes elements of hospital-based care, 24/7 phone support and daily home visits.

Frequently Asked Questions

How can we help?

  • Address your medical, functional, nursing and psycho-social needs.
  • Educate you and your caregiver on managing your chronic diseases and physical care
  • Reduce your acute hospitalisations
  • Connect you to community partners, including GPs and Voluntary Welfare Organisation (VWO) community service providers, to address your long-term healthcare needs

Who is suitable for AIP?

  • Patients from KTPH and YCH who are to be discharged and need further care at home
  • Patients who are identified as likely to require re-admission to the hospital
Community Nurse Posts

Our regional teams work alongside residents and partners to maximise community support and resources for health resilience and empowerment. These teams include nurses, healthcare assistants, community connectors, and allied health professionals.

At our Community Health Posts in Yishun and Sembawang, residents can access care services offered by community nurses and connectors conveniently in their neighbourhoods.

At CHPs, residents can receive health information, support in managing chronic diseases, health coaching, and introductions to other community resources. These CHPs are located in visible, convenient spaces within the neighbourhoods of Yishun and Sembawang. Overall, we aim to build up residents' capability and capacity to self-care.

Our CHPs partner with GPs, polyclinics, active ageing centres, home care providers, and other community resources to support you in managing your health.

Why Visit the CHP?

At the CHP, you will be able to meet with our community nurses and regional connectors.

Our services:

  • Check blood pressure, blood sugar, height and weight
  • Learn about healthy lifestyle choices
  • Build a personalised care & support plan
  • Ask questions about your medication and risk of falls or memory loss

We hope to support you in being an active participant in your own health.

Frequently Asked Questions

Where and when are the Community Health Posts?

Who can I contact for more information?

Tri-Generational Home Care @ North West (TriGen)

TriGen was started in 2014 as a project for student volunteers to support older adults in the community. It is a partnership involving North West Community Development Council (NWCDC), Yishun Health (YH), National University of Singapore (NUS) and secondary schools in the north of Singapore.

Interested to be a part of TriGen? For more information on TriGen, please visit our website

Frequently Asked Questions

What does TriGen do?

NUS students from the Medicine, Nursing, Pharmacy and Social Work faculties are trained by our multidisciplinary community care teams, and the NWCDC in healthcare and social service skills, and emergency response. The students make fortnightly home visits to older patients of our community care programmes. The aim is to reduce hospital re-admissions of frequently admitted patients.

What roles do students play in TriGen?

  • University students conduct routine health checks and evaluate the patients’ medical, social and financial conditions. They act as an extended arm of our community nurses, helping to keep a lookout for the elderly and raise potential issues.
  • Secondary school students offer companionship through befriending and interactive activities.

Who does TriGen support?

Residents receiving care and support from our community nurses may be introduced to TriGen.

GeriCare  

Who We Are

GeriCare develops partnerships between Khoo Teck Puat Hospital and nursing homes to enhance care for nursing home residents. We aim to increase access for nursing homes to specialised geriatric and palliative care, and conduct training and preceptorship at nursing homes. 

What We Do

Clinical Care

Enhance quality of care in nursing homes (NHs) and increase accessibility to specialised geriatric and palliative care

i. TeleGeriatrics (TeleG)

  • Consultations via video conferencing for NH residents with hospital specialists

ii. Tele Mortality Audit

  • Joint review of death cases by NH nurses and hospital doctors to address possible gaps in care via video conferencing

iii. Tele Multi Disciplinary Meeting

  • NH healthcare team and hospital doctors collaborate to establish the best care plans for NH residents via video conferencing

iv. GeriPall

  • Preceptorship for NH nurses through bedside supervision, role modelling, and on-the-job training
  • Nursing consultations via TeleNursing for NH residents with palliative trained nurse

v. In-person consultations

  • Physical visits by doctors to NHs to help treat, care and manage the NH residents

Training & Education

Build and enhance clinical knowledge and competencies of NH staff in geriatric and palliative care

i. Palliative Care Course for Long-Term Care nurses

  • Enhance competencies of nurses to provide quality care for their residents who are nearing end-of-life

ii. TeleGeriatrics Nurse Training Course

  • Equip nurses with knowledge and skills to deliver quality person-centered geriatric care

iii. Advance Care Planning (ACP)

  • Train NH staff to facilitate ACP conversations with their residents and family members

iv. Tele Continuing Professional Education

  • A platform for NHs and partners to exchange best practices and learn from experts via video conferencing

v. Situation-Background-Assessment-Recommendation Online Course

  • Equip NH staff with a structured and easy-to-use tool for effective communication

vi. PowerFacts Course

  • Bite-sized animated videos centering on healthcare issues such as Palliative Care and Geriatric Care

Research and Education

  • Conduct research with NHs to enhance quality of care in NHs
  • Implement quality improvement programmes
  • Guide and support NHs to conduct research projects
  • Collaborate with academic institutions

“

TeleG makes consultation with specialists more convenient and accessible. Symptomatic residents can be reviewed through TeleG and treatment given promptly. This reduces unnecessary hospitalisation.

Villa Francis Home for the Aged

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Frequently Asked Questions

Who can benefit from GeriCare?

For nursing homes partnering with GeriCare:

  • Nursing home residents benefit from the clinical care provided by our hospital doctors via teleconsultations and physical visits
  • Enhance the knowledge and skills of nursing home staff in geriatric and palliative care

Where can I find out more about GeriCare?