SingHealth Regional Health System (SouthEast) introduced Community Nursing Programme in February 2018 with the aim to anchor population health and bring person-centred healthcare beyond hospital walls.
The team provides the fully subsidized, accessible healthcare services through nursing consults at Community Health Posts, extensive community outreach efforts, capability building & partnerships. Since July 2023, the community nursing team has evolved as part of the Place-based Care Teams (also known as Healthier SG Teams) that comprise of community nurses, wellbeing coordinators, and care coordinators.
The team provides the following services for residents of various health segmentation:
Pre-frail
| Frail/ requiring assistance in managing chronic conditions
|
Community Health Talk
Health Screening and coaching Community Falls Prevention Programme Individual and group health interventions: smoking cessation, weight management, general Advance care planning
| - Health and geriatric assessment
- Health coaching for disease prevention
- Chronic disease monitoring and self-management education
- Medication consolidation, self-management support and education
- Case management and coordination
- Social prescription
- Caregiver training and support
- Advance care planning/ Preferred plan of care
|
Requiring complex care
| Very frail/ requiring supportive and palliative care
|
- Home-based Community Outpatient Parenteral Antimicrobial Therapy (COPAT)
| - Generalist Palliative Care in the community
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