Community Resources

Be Supported

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.

SSN Kimberly Lim rendered excellent service. She was patient and thorough in her follow up. Kimberly is caring and is respectful towards her client and family. It has benefited my mother who was far too frail post-discharge to be shuttling to and fro the hospital for her follow up appointment.

Thank you PT Rachel Koh for the tips and advice, and going the extra mile to arrange an appointment at KTPH. Thank you for making my mom more confident and positive.

SSN Winnie Fok often calls to check on me. MSW Jovina also calls me often and arranged for my Medifund procedures and my escort services, telling me not to worry. Overall, I had a very good experience with the staff of this home care service.

Frequently Asked Questions

How can AIP-CCT support you?

Our home visit services support you in:

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

Who can benefit from AIP-CCT?

  • Patients from KTPH and YCH who are need further care at home after being discharged.
  • Patients who are identified as likely to require re-admission to the hospital.
 

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.

Our community nurses form the backbone of community care from prevention to end-of-life. Hence, Community Nurse Posts (CNPs) are one way in which we aim to improve access to health in the community.

At CNPs, residents can receive health information, support in managing chronic diseases, health coaching, and introductions to other community resources. These CNPs are located in visible, convenient spaces within the neighourhoods of Yishun, Sembawang and Woodlands. The community nurses also proactively visit patients who are not mobile. Overall, we aim to build up residents' capability and capacity to self-care.

Our CNPs partner with GPs, polyclinics, senior activity centres, home care providers, and other community resources to support you in managing your health.

Our 2S+2C community nursing approach

  • Sensing the ground for assets in each neighbourhood, and working with partners to support residents in the community
  • Strengthening individuals and families with appropriate care options to self-manage their health
  • Care provision through individual assessments and care plan co-developed with residents and their care providers.
  • Coordination between health and social care, and between residents and community partners to enable residents to self-manage their chronic conditions

Why Visit the CNP?

Our nurses will get a deeper understanding of your specific medical, social and even family and financial circumstances. They can customise your care plan and make joint decisions with you in your care. For example, our nurses may jointly decide with you to cut down on less essential medication. They may also link you up with social support services.

You will rely less on medication and be a more active participant in your own health.

Frequently Asked Questions

How do our community nurses help?

We offer preventive care and chronic disease management services including:

  • Chronic disease monitoring (BMI, blood pressure, blood sugar)
  • Health counselling and coaching
  • Medication review and advice
  • Memory screening
  • Fall risk screening

Who can I contact for more information?

 

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.

 

Who We Are

GeriCare develops partnerships between restructured hospitals and nursing homes to enhance care. We aim to increase access for nursing homes to specialised 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 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

v. NH visits

  • 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. GREAT Course

  • Build capabilities of NH staff to provide basic geriatric nursing care for their residents

iv. Advance Care Planning (ACP)

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

v. Tele Continuing Professional Education

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

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

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?