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 medical illness $15-$25; Chronic illness $25-$40
Majority of our patients receive MOH subsidies which we try to utilise as much as possible for the benefit of all our patients.
MOH subsidies for holders of Blue CHAS, Orange CHAS, and Pioneer Generation cards
Drugs at polyclinic rates (follow-up visits for chronic disease)
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.

Care Management Services, Hua Mei Clinic

An integral component of the Person Centred Medical Home* model at ComSA, the care management services provide home-based care for community-dwelling frail elders. The multidisciplinary team, which consists of nursing and social work professionals, aims to ensure that older persons are equipped and prepared to age well in the comfort of their own homes. The service is intended for older adults aged 40 and above, living within a defined boundary of the Whampoa* area, and have high bio-psycho-social care needs.

Through comprehensive assessments, the team identifies care needs and connects clients to services and resources in the community, working with family members and other medical and social partners.

*including Balestier, Towner, McNair

Dementia Care System, Hua Mei Clinic

Dementia Care System (DCS) provides a system of medical, social and emotional care to home-dwelling elders with dementia and simultaneously supports their caregivers and family members. It aims to establish an optimal state of well-being in elders with dementia; empower care partners to be competent, confident and minimise use of hospital resources, delay the need for residential skilled and nursing facilities.

This is a physician-enhanced dementia-specific care management programme that supports persons with dementia (PWDs).

Intellectual Disability Service, Hua Mei Clinic

The Intellectual Disability Service (IDS) is an integrated primary health and psycho-social care management programme targeted at adult persons with intellectual disabilities and their ageing caregivers.

The programme aims to improve the health and well-being of adult persons with intellectual disabilities and their caregivers in the following key areas:

Health
Behaviours
Communication
Psycho-emotional support
Function and social integration
Mental capacity assessment and future care planning

Both the adults with intellectual disability and their caregivers are direct beneficiaries of the service, and their needs are assessed and supported alongside each other. The service is targeted at:

Adults with intellectual disability aged 40 and above OR
Caregivers who are 60 years or above, island-wide.