Putting the Social into Healthcare17 Apr 2019

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NUHS envisions

A Healthy CommunityShaping Medicine . Transforming Care

To advance health by synergising care, education and research

in partnership with patients and the community

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Alexandra

Health Campus

NUHS Community

Campus

Kent Ridge

Health Campus

Jurong Health

Campus

NUHS Community Campus, together with the three Health Campuses, will

work to support residents in improving their health and remaining in the

community.

Adoption of a 4-Campus Model for NUHS – Integrate & Anchor Care in the Community

A Healthy CommunityShaping Medicine ∙ Transforming Care

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Promotes joint

ownership for

community care within

NUHS – collaborative

efforts among four

campuses (and NUP),

led by NUHS Community

Campus – in

collaboration with

community partners

Population in the West

Kent Ridge

Health Campus

JurongHealth

Campus

Alexandra Health

Campus

Primary Care

Intermediate &

Long-term Care

NUS, Grassroots,

social & private

organisations

NUHS

Community

Campus

Hospital (NUHS Health Campuses)

Community partners (working in

collaboration with NUHS

Community Campus)

RHS

NUHS Community Campus: Model of Care

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Community Health Post (CHP) - an extension of NUHS Community Campus services within Community

CommunityCampus

Hospitals / ILTC

Community Hospitals

NursingHomes

NUH NTFGH

AH

• Coordinate care• Co-manage patients• Tap on resources

CommunityHealth

Post

CommunityHealth

Post

CommunityHealth

Post

CommunityHealth

Post

CommunityHealth

Post

CommunityHealth

Post

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Building a healthy and engaged population

NUHS Community Health Post(In collaboration with Community Partner)

Local Community(Residents / NOK)

Polyclinics

Grassroots

GP/PCN/ FMC

Other Community Services and Partners e.g.

NUS

SocialOrganisations

• Aim to:• increase accessibility

to healthcare• empower residents to

take care of their health

• Community Care Team• Community Nurse

(v1.0)• Community Health

Manager (trained layman)

• Allied health

Community care team

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Aim to achieve community health goals

• Improve health literacy

• Empower patients/residents to take care of health

• Help residents to lead a healthy lifestyle

• Manage their chronic diseases better

• Tag every patient/resident to a primary care doctor

• Fulfil the elements of Prescriptive Plan (PP)

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Prescriptive PlanA population-based preventive and management plan for adults and seniors

• Plan to keep adults and seniors healthy and delay the onset of disease and

frailty

• Recommends suite of evidence-based preventive health services and

interventions

Chronic Disease

Screening

Obesity

Hypertension

Diabetes

Hyperlipidaemia

Cancer

Screening

Colorectal Cancer

Cervical Caner

Breast Cancer

Other

Screenings

Functional Screening

Frailty Screening

Vaccination

Influenza

Pneumococcal

Chronic Disease

Management

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NUHS started with community nursing services at CHP (v1.0)

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Medication Reconciliation & Upskilling resident to

pack her own medication

Nurse Counselling

Performing Frailty Assessment

• Support and educate the residents to understand and manage their own

health through formulating a personalised care plan

• Engage and provide training sessions for the population in the community to

increase their health literacy

Health Talks

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Collaboration with Lions Befrienders on CHP

• Pilot a model of managing a population with a Social Care partner

• Lions Befrienders’ vision: A nation where every senior is active, healthy

and happy

• Project site: Lions Befrienders’ Mei Ling Street Senior Activity Centre

(SAC) - 3 rental blocks (290 seniors)

• Started in July 2018. LB staff actively outreach to seniors. A total of 139

seniors.

1 N = 139; number of individuals seen in Queenstown SAC

Blk A(41.4%)

Blk B(18.5%)

Blk C(22.9%)

Others(17.1%)

Block A

• 58 seniors (41%) are

“enrolled” at our CHP.

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Together we inform, “reform” and transform

• Have the needs of residents at the heart of the project

• See healthcare as one of residents’ needs. Move away from

multiple programmers’ perspective. Operate as one team.

• Co-create the model with NUHS: Social - Health Integration

• LB’s other services co-locate near the SAC – home personal

care & cluster support

• Share data to provide more holistic care to residents

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Involvement of residents is most important

Outreach Reach out to the seniors e.g. door-knocking

and “breakfast programme”.

Trust

Buy-in of seniors through building

relationship and close follow-up. Winning

their trust that we are there to stay and care

for them.

Resource CHP as a healthcare resource to seniors.

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Key needs identified at CHP and follow up

Assessment of Health Needs

The common health needs identified include:

• Chronic Disease (DHL)

• Cognitive Impairment

• Frailty

• Unhealthy Lifestyle

• Medication Management

Follow-Up and Interventions

Interventions and referrals were done to address those needs, including:

• Patient education

• Arrangement of home visits

• Referrals to GP and Polyclinic

• Subsequent Review at CHP

141 N = 56

Profile of Blk A seniorsChronic Disease Prevalence

F/U for

DHL mgt

To check for status

of DHL Screening

67%with at least one

chronic condition1

17%with three

chronic conditions1

1 in 3 have

Diabetes

3 in 5 have

Hypertension

1 in 2 have

Hyperlipidaemia

High prevalence of chronic disease among residents - CHP provides health

education to the population on chronic disease management, and integrates with Primary Care for further interventions

0(32.8%)

1(17.2%)

2(32.8%)

3(17.2%)

Number of Chronic Disease1

(% of individuals)

15

0

20

40

60

80

Very Fit Well ManagingWell

Vulnerable Mildly Frail

Profile of Blk A seniorsClinical Frailty Score

Clinical Frailty Score1

12% (~1 in 8 residents)

requires additional

follow-up

1 N = 56

Residents generally coping well (88%) – CHP provides education on falls prevention

and regular reviews, with SAC supporting residents in daily activities and encouraging

them to remain active.

For frail residents, nurses will provide home visits.

% o

f se

nio

rs

CFS Status

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Profile of Blk A seniorsCognitive Status

1 N = 52. Those mini-cog with score 0 – 2 require further follow-up.

CHP has identified a significant proportion (50%) of residents with high likelihood

of cognitive impairment (followed up with Primary Care for further assessment

and intervention).

10.5%8.8%

21.1%

14.0% 14.0%

22.8%

0%

10%

20%

30%

0 1 2 3 4 5

Mini Cog Score1

50% (~1 in 2 residents)

requires additional follow-up

% o

f se

nio

rs

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Case Study 1

• 77-year-old, widowed, lives alone in rental flat

• Has hypertension and hyperlipidemia

Mdm C’s Profile

• Coordinate care between Primary Provider and Social Partner.

• Improve patient safety• Provide patient education

Issues Identified

Fall at home

s

Confused about medication Strained relationship with son and daughter-in-law

(

What did we do?

Education on medication

regime

Medication reconciliation, provided pillbox and

guided Mdm C inself-pill packing

Facilitated early review appt at QT polyclinic,reduce medication to

2 types

Encouraged her to attend functional

screening

Senior group home staff visit frequently and monitor BP

Result:

Mdm C is able to self pack her medication correctly for 3 visits

Mdm C is taking her medication correctly

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Case Study 2

• 87-year-old, single, lives alone in rental flat

• Community ambulant with walking stick• Diabetic, Hypertension, Hyperlipidemia,

IHD, BPH, Anaemia, H Pylori, Gallstone, PVD

• F/u @ Queenstown Polyclinic and SOC

Mr K’s Profile

• Coordinate care between Primary Provider & Social Partners

• Provide patient education• Improve compliance in medication

and medication safety

Result:

What did we do?

Educate on medication, reinforce compliance

Provided pillbox, CHP nurses guide him to self-pack weekly (unable to

do it independently due to poor vision)

Regular home visits by cluster support to check on

medication compliance

Facilitated early appointment at QT polyclinic for eye review

Motivated him to participate in SAC activities

Persuaded him to agree to Home Help services twice a

month

Issues Identified

15.1

163/83

Poor BP readings and blood sugar levels

Not compliant in medication -defaulted insulin, mistakes

dosage of medication.Refused medication packing due

to cost

Visualimpairment

Compromised personal

hygiene/home cleanliness

Improved personal hygiene/home cleanliness

Improved medication

compliance

Improved BP readings and

blood sugar levels

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Key learning from our journey together

• Take a leap of faith

• Leverage on partners’ strengths

• Build trust and rapport with residents

• Appreciate social realm is important to the overall health

• See the change in behavior of our seniors

Moving ahead

• Expand the role of SAC

• Expand model to other sites and enhanced model of CHP

v2.0

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Thank You