Integrated Care System


ComSA aims to create a sustainable integrated health and social care system that promotes health over the life continuum and enables ageing in place.

This is underpinned by robust care management and the person-centred medical home, whereby care is comprehensive, coordinated, accessible, and delivers on quality and safety. (See pcmh.ahrq.gov)

To reach its goal, ComSA takes a population-based systemic approach, engaging the collaboration of grassroots and civic organisations, health and social service providers, research analysts, policymakers and other stakeholders in Whampoa.

Key pieces in this plan are:

1. The development and implementation of a community risk screening tool which enables high risk elders to be identified for early intervention
   
2. A stratified care management service capable of supporting elders and their families with simple to complex needs
   
3. The person-centred medical home working in integration with care management to provide primary health and social care to elders with the most complex needs, as well as to their families
   
4. A para care manager system led by trained volunteers to support the work of the care managers
   
5. A coalition of service providers contributing to a seamless interface of service delivery across multi-sectoral interventions
   
6. Support for capacity building in eldercare skills and knowledge in Whampoa
   

 

Hua Mei Clinic, Whampoa Centre

Hua Mei Clinic is a person-centred primary healthcare practice that promotes comprehensive biological, psycho-emotional and social health and wellbeing along the life-course and supports the wish to age at home, among friends and family. It is modelled after the USA-originated Person-Centred Medical Home (PCMH) concept.

 

Service Options:
One or more of these services at Hua Mei Clinic is offered to the client, depending on his/her healthcare needs:

  • Medical care such as health promotion, the management of long-running chronic disease and frail care
  • Care management for more complex needs - comprehensive assessment of bio-psycho-social conditions, care planning and service coordination for the client to age at home at optimal wellbeing
  • Counselling for the individual and family
  • Service information and referral to support caregiving and the health and wellness of older persons

Healthcare delivery is team-managed by the Clinic’s physicians, nurses, social workers and counsellors and supported by partnering health and social service agencies operative in Whampoa. Hua Mei is a CDMP (Chronic Disease Management Programme) accredited clinic.

Eligibility:
Whampoa residents assessed by the ComSA health screener or referred by Tan Tock Seng Hospital. Fees and Charges:

  • Medical Consultation: Acute illness $20 per visit; Chronic illness follow-up visits: $30 - $40 per visit
  • Drugs at polyclinic rates (follow-up visits for chronic disease)
  • MOH subsidies for holders of Blue CHAS, Orange CHAS, and Pioneer Generation cards
  • Care management, Counselling and other services: Fees on a sliding scale, depending on income

 

Centre-based Comprehensive Care

Hua Mei Elder-centred Programme of Integrated Comprehensive Care (EPICC) serves older persons who wish to continue living at home in spite of their complex medical conditions and limited family and social support. It provides team-managed, person-centred, integrated comprehensive care, with a day club programme.

 

Care delivery is team-managed by physician, nurse, social worker, physiotherapist, occupational therapist, day centre manager, programme assistants, administrative assistant, and driver.

Personalised service suite:
The frequency and extent of these services offered to each EPICC participant depends on his/her personal needs will vary:

  • number of days attending the day club programme (6 hours a day)
  • door-to-door transport service
  • medical care and daily monitoring
  • 24-hour medical hotline
  • exercise programme, physiotherapy and physical rehabilitation
  • social care services
  • counselling service
  • home help services
  • social engagement, arts and recreational activities

Hua Mei EPICC at ComSA replicates the pioneering programme by the same name that the Tsao Foundation has operated successfully at Tiong Bahru since 2011. It is modelled on the widely accepted Program of All-inclusive Care for the Elderly (PACE) in the USA.

Eligibility:

  • Persons aged 60 years and above with complex care needs
  • Living in Whampoa and surrounding areas
  • Referred through Agency of Integrated Care (AIC), Ministry of Health
  • Other referrals: upon consultation with EPICC staff

Fees and Charges:
These are on sliding scale, depending on the health and social circumstances of the older person and family.