Central Regional Health System. ComSA Launch 11 Apr 2015
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1 Central Regional Health System ComSA Launch 11 Apr 2015
2 Assigned Regions by Planning Area & Population (as at 2013) Total Pop: 5.18M (2011) >65yr (42K) KTPH (0.69M) CGH (0.94M) >65yr (82K) >65yr (118K) NUH (1.46M) AH SGH (0.68M) Incl Punggol (88K) & Sengkang (234K) >65yr (71K) TTSH (1.40M) Incl Hougang (297K) & Serangoon (169K) >65yr (168K) Source: Ministry of Health, 4 Feb 2013 For Healthcare Clusters Planning Use Only 2
3 Climate Why RHS? o Ageing o Increasing expectations o Changing social support o Manpower constraints o Rising costs o Knowledge explosion o Increasing complexities o Inconsistency and unsafe care o Narrow window of opportunities [3]
4 Goal RHS : Relationship Based Healthcare that is Sustainable [4]
5 RHS Formula o Focus on the 20:80 o Majority of Future Needs are Preventable o Better Detection and Earlier Intervention o Stabilize the Population You Know o Shift to a Lower Cost Model Away from hospital centric Away from doctor centric Away from face to face Away from variations Patient receiving care to self-care o Integrate for efficiency, convenient and coordinated care
6 Segmenting Our Population Unknown (70-80%) Outreach Approach 1. Lower SES : Case finding for residents of rental flats (Priority 5) 2. School kids : Partner with HPB School Health 3. Working adults : Workplace Health/Partner with MOM 4. General population : Community & opportunistic screening Known Approx 320,000 in Central Region (20-30%) Health Status Well / At Risk Pre-Clinical Chronic Illness Progression/Complication End of Life Led by Community Primary Care Hospital Palliative Health Coordination Automated reminders at set intervals Automated monitoring, escalation when needed Care Co-ord by Healthcare Professional Case Management Goal(s) Maintain health Prevent onset Delay progression Maintain function, rationalise care (FP, SOC), pre-empt complications, avoid admission Stabilise, restore function where possible, avoid admission Minimise pain, avoid admission
7 RHS Build Out Phases Phase 1 Coordinating & Integrating Care 1.Build capability 2.Integrate care for frail and complex 3.Develop pilots and new models Phase 2 Developing Care Packages for the Known 1. Stratify into sub-population 2. Understand needs 3. Develop appropriate care bundles 4. Pilot 5. Spread Phase 3 Understanding the Unknown 1. Opportunistic screening 2. Targeted population case finding/interventions School going age Employee health Lower social economic status Optimise Current Care System Optimise Current Patients Optimise Future Populations
8 Our Current Programs at a Glance Health Status Well / At Risk Pre-Clinical Chronic Illness Progression/Complication End of Life ACTION / Interim Care Giver Project CARE PACH / Home Ventilator Service Project PreCARE Team Based Primary Care FA Capitation Pilot Home Care FMC / CHC / GP Partnerships Opportunistic Health Polyclinics Rental Flats Case Finding/CHEP
9 (Mobile) Community Health Centre Services Offered : Diabetic Retinal Photography Wider geographical coverage and hence nearer to residents and GP Clinics Bishan-Toa Payoh, Hougang-Serangoon, Whampoa-Kallang Operating on board 24-seater Started Nov 2014 Diabetic Foot Screening Nurse Counselling for Chronic Diseases
10 Access to Drugs ComSA Doctor: 1.To fill in prescription slips and faxed over to TPY Pharmacy at the end of each consultation TPY- Pharmacy: 1.To check Rx is completed and do quick reg. in epos 2.To register patient as subsidized outpatient 3.To process and dispense prescriptions 4.To prepare medications for same week batch collection TPY- Clinic Ops: ComSA Staff/Volunteer: 1.To tag patients as ComSA 2.To close bill 1.To bring original prescription slips 2.To collect medication and invoices (payment via Giro)
11 Supporting the Frail o Health managers at acute, primary & community care act as the care co-ordinator for each resident FSC Community-based Care Manager Collaboration SAC (Cluster), SCC o Pairing the FA resident with trained volunteers: to keep patients well in the community Community Mental Health
12 Many Hands
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