Community Case Management Service (CCMS) Case Managers Go the Distance

For the past four years, Mdm Lim* has been juggling household chores while caring for her husband, who has multiple chronic conditions. Taking care of his daily needs required Mdm Lim to lift, transfer and clean him. This took a toll on Mdm Lim physically. In addition, the financial stress of not having a breadwinner in the family also affected their relationship.

Their case was referred by the Agency for Integrated Care (AIC) last year to Montfort Care, a service provider under the Community Case Management Service (CCMS) programme.

What’s CCMS?

The Community Case Management Service (CCMS) aims to deliver holistic care centring on needs of the elderly. This is especially relevant for frail seniors with multi-faceted care needs that may grow increasingly complex over time.

By coordinating community-based aged and social care services required by seniors, seniors are encouraged to stay in the community for as long as possible, giving them the choice to age in place.

The CCMS programme aims to:

●     Address clients’ holistic care needs (medical, functional, behavioural and psychological)

●     Promote and improve clinical outcomes

●     Coordinate support services to suit clients’ needs, goals and priorities

●     Assist clients in accessing care options and resources

●     Promote appropriate usage of community resources

●     Advocate clients’ best interests

●     Improve clients’ quality of life and caregivers’ satisfaction

Who provides this service?

CCMS started in 2014 with just three providers - namely, AMKFSC Community Services Ltd, St. Andrew's Community Hospital and Tsao Foundation. Today, the programme is now available in more areas of Singapore with three new providers joining in - Fei Yue Community Services, Montfort Care and St. Luke's Eldercare Ltd.

mosAIC speaks to two of the providers, Montfort Care and Fei Yue Community Services, to find out more about their services.  

Montfort Care – Helping clients navigate care options

Montfort Care’s area of coverage:
East Coast GRC, Marine Parade GRC, Radin Mas SMC

CCMS cases are usually referred to Montfort Care by AIC’s CCMS and Community Networks for Seniors (CNS) teams. In the case of Mdm Lim, Montfort Care’s social worker, Edwin Soh, shared that he and his CCMS team helped the elderly couple to navigate and access the varied care options and support services. Beyond healthcare needs, Edwin recognised that Mdm Lim has been experiencing caregiver stress. He made himself contactable to ease her worries and build trust between them.

Edwin said that while care services have always been available for Mdm Lim and her husband, they had no knowledge of the services. This is why CCMS is such a vital programme, and why the CCMS team must understand their clients’ full situation to help them get the right services.

“Given that we engage the client and family very closely, we usually have a better understanding of their needs and family dynamics. As such, we advocate the family’s needs where necessary. This allows us to work with the service providers to coordinate timely services for the family’s needs.”

Fei Yue Community Services – A collaborative approach to care

Fei Yue’s area of coverage:

Holland Bukit-Timah GRC, Yew Tee-Marsiling GRC, Choa Chu Kang GRC

Catherine Heng, who was a Home Care Nurse in a restructured hospital before she joined the Fei Yue’s CCMS team, said the service is a collaborative effort between various sources, such as AIC, CNS and hospitals.

The team makes sure that the clients referred to them are assessed based on their background information and their current conditions or issues. “We would also do a background check to verify if the senior already had other formal services in place so that there will not be duplication of services and we seek to collaborate with other community partners who might already be acquainted with the senior,” said Catherine.

As a trained nurse, she helps her clients monitor their blood pressure, measures blood glucose (for those with diabetes) and assists them in managing their medication. She often meets clients who do not comply with their treatment plan. As part of the CCMS team, Catherine would try to understand why these clients do not heed their doctors’ advice – which could be due to discouragement or setbacks from long-term illnesses or medication misconceptions.

Catherine also helps to link various service providers to clients when the situation calls for it. When one of her clients’ progressive lung condition began to worsen, she engaged the Social Service Offices financial assistance, called upon the Southwest CDC and Red Cross Ambulance for transportation needs, and worked with St Luke's Hospital for home personal care.

Catherine shared that her client progressed from an independent way of life to becoming home-bound and reliant on a long-term oxygen therapy machine. However, the older lady’s spirit never wavered. She has inspired Catherine and her team to continue this important work.

“My client has always kept a positive outlook towards life and made the most out of her situation to the best of her ability. Her zest for life has definitely influenced me to learn to look for the good in every situation.”

*Names have been changed to protect the privacy of individuals.