Thursday, September 16, 2021

Communities of Care: A Journey Towards Building a Seamless Care Ecosystem for Seniors


As part of a nationwide effort for seniors to age in place, the Community Care sector is continuously looking at greater integration with agencies and partners, strong local care coordination and developing seamless care journey for our seniors. A new initiative was piloted across 14 sites islandwide in a project called Community of Care (CoC) pilots, supported by the Tote Board Community Healthcare Fund (TBCHF).

A robust and well-coordinated care ecosystem is essential to spur the growth and quality of care in our community, so as to enable our seniors to age better in place. mosAIC finds out how CoC pilot projects have been progressing for three Community Care organisations: Montfort Care, Fei Yue Community Services, and Tzu Chi Foundation.

Montfort Care PACE-s Toward Digital Connectivity Between Seniors and Care Providers in Marine Parade

Montfort Care (MC), a Family Service Centre in Marine Parade that started in 2000, provides comprehensive social services for the community. In their efforts to better integrate social and health care to coordinate better and timely care for seniors, they collaborated with SingHealth Polyclinic to develop a mobile application, PACE-IT. The app is simple yet intuitive, and allows timely and effective communication to provide person-centred care to seniors. As of August 2021, MC has screened over 315 clients, identified 61 potential clients and enrolled 25 suitable seniors through PACE-IT.

The Montfort Care CoC project team. Photo was taken before the COVID-19 pandemic.

The collaboration with SingHealth Polyclinic also led to new initiatives such as the Tele-Health Senior Services, a video call initiative that started in in July 2020 for seniors to undergo medical consultations without travelling to SingHealth Marine Parade Polyclinic. As of August 2021, 84 video consultation sessions have been successfully conducted.

MC is working towards a comprehensive and cohesive healthcare system by using technology to provide holistic and person-centred care plans for seniors. With a single touchpoint that combines the unique specialties of care partners, seniors' care can be effectively communicated and coordinated.

Tzu Chi Foundation (Singapore) Solidifies Community Care Linkages in Bukit Batok

Tzu Chi Foundation (Singapore) (TCF) organises charitable activities, medical services, and humanistic education to meet the needs of the Bukit Batok community, especially seniors. To assist seniors to age in place, TCF identifies care gaps in the Bukit Batok community and addresses the fragmentation of care services to seniors.

At the start of the pilot, TCF first ran resident profiling and block mapping to pinpoint care gaps. In collaboration with St Luke’s Hospital (SLH), they then set up the RedCAP system, a secure web application that seamlessly integrates online and offline data for research studies. TCF also upskilled their team and involved IT experts to ensure the security and compliance of their data management.

Next, TCF and their partners developed a standard triage tool to assess seniors' healthcare and social needs with the data acquired. The triage tool is used to monitor Bukit Batok seniors' needs and determine the urgency of care. TCF would also get the support from partner providers for services such as personal home care and medical escort when service referrals were required.

Bukit Batok seniors taking part in the Pail-for-Frail exercise, part of SLH’s Western Silvercare programme.

As part of the CoC pilot programme, the seniors were also encouraged to take part in customised programmes such as SLH’s Western Silvercare, locally known as Jin Jia Ho! or Bagus!. This programme aims to reduce or reverse frailty among seniors. It also provides comprehensive screening, assessment and intervention to address seniors' medical, physical, nutritional, cognitive and psychosocial needs.

TCF noted that while the seniors were initially hesitant to take part in such programmes, they saw an uptake in participation rates since the launch of CoC pilot. As of June 2021, 43 out of the 66 screened seniors have been successfully enrolled in the Western Silvercare programme. They also noticed an increase in seniors accepting assistance in service referrals like personal home care and medical escort service.

Over the three years of TCF running the pilot programme, they successfully made 339 engagement contacts from their assigned 22 blocks. They continue to reach out to seniors as TCF estimates over 1,500 seniors available to participate in the programme. TCF and its partners' proactive and integrated response system remains a work-in-progress to reduce fragmentation amongst care services and seniors in the community.

Fei Yue Takes a Senior-centric Approach For Its CoC Pilots

Seniors attending an exercise class, with social distancing measures in place.

Fei Yue Community Services (FYCS) is also part of the CoC pilot programme, which is running between October 2019 and March 2023. FYCS provides healthcare support in the form of mental health support, home care support, caregiver support and respite options, and more. Besides providing direct healthcare services, they also offer counselling services, as well as equipping and training courses, serving the communities that range from the young to the old.

The FYCS team, together with SLH, spearheaded Western Silvercare, described above. As of June 2021, they have engaged 120 seniors to be part of the project, and are on track to achieving their target of 130 seniors by October 2021.

As part of the CoC pilot, FYCS also rolled out several programmes with Ng Teng Fong General Hospital (NTFGH), such as:

  1. My Health Map: A plan to alert seniors on necessary screenings to identify potential illnesses early.
  2. Adopt 210A: A programme that provides help for seniors residing in Bukit Batok rental units.
  3. Auto Alert Hospitalisation: A standard operating procedure that automatically alerts FYCS's staff upon the hospitalisation of seniors to provide a comprehensive care plan, including their discharge plans.

FYCS's CoC pilot fostered strong collaboration with hospitals, Community Care providers, social agencies, and donors to bring an integrated social-health service to seniors of Bukit Batok.

Learnings and Challenges of the CoC Pilot Programmes

While the CoC programme seeks to provide a centralised system for coordinated efforts, different Community Care organisations found similar challenges in integrating operations with their partners.

For one, MC had to work through data sharing details with SingHealth Polyclinic to share seniors' information across various care teams while ensuring compliance with the Personal Data Protection Act (PDPA).

The team at TCF noted that they had to spend time to sync up their processes with partners to ensure minimal duplication of efforts by all parties.

As for FYCS, the pandemic posed challenges and restrictions in terms of the number of seniors entering their centres, which led to a disruption of the seniors' progress in participating in specific programmes.

Next Steps

The importance of establishing a defined set of operations procedures, identifying clear roles and responsibilities were amongst the key learnings from the different CoC pilots.

If you are keen to find more about how TBCHF can assist organisations in dynamic operations and partnerships, visit or drop us an email at

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