NHG NURSING STRATEGIC MAP
Group Nursing developed the NHG Nursing Strategic Map to achieve the strategic goal: “NHG Nurses are trusted and chosen to provide expert advice, decisions, and care.” This would be attained through four strategic thrusts across the five care segments of NHG’s River of Life framework:
- Relationship-Based Care establishes trust-based relationships with patients and their families to ensure continuity of care.
- Nurses beyond Nursing, Nursing beyond Nurses encourages staff to gain mastery of nursing practice, and adopt trans-disciplinary competencies to add value to the care of patients and their families.
- Digitally-Enabled Workforce harnesses technology to enable timely solutions and interventions at any time, any place, and continually spurs innovation in the way we deliver care.
- Positive Practice Environment builds a shared governance culture that engages, encourages, embraces, and empowers NHG Nurses.
NHG COMMUNITY NURSING
The NHG Community Nursing Committee was set up in end 2017 to harness best practices and develop holistic, patient-centred, and nurse-led care in the community. It serves as a central platform to oversee strategies, provide actionable resolutions, and continuously improve the standards of community nursing across the care continuum. This is underpinned by the 2S+2C concept and The Omaha System, embedded in our community nursing’s clinical protocols, workflows, and nursing competency.
2S+2C Concept
SENSING
Encourages community nurses and lay extenders (or community care associates) to consolidate data on at-risk individuals/clients to address their needs proactively/preventively in a timely manner. This is achieved by connecting with individuals, families, grassroots organisations, and providers in the community.
STRENGTHENING
Focuses on improving knowledge and skills of individuals and families to exercise self-managed care, and equipping community partners with the capability to better support and complement health and social care.
CARE
Hones in on developing the required competency to provide appropriate clinical and social care through assessment, care planning, interventions, and escalation/de-escalation of care.
COORDINATION
Enhances seamless care by working closely with the various levels of community of carers and partners to maintain optimal function of individuals in the community.
DEVELOPMENT OF CLINICAL WORKFLOW
The NHG Community Nursing developed four clinical workflows to manage functional ability and falls, cognition, diabetes, and depression in the community. These nurse-led clinical workflows guide the care delivery for clients and/or caregivers with existing chronic diseases such as dementia and diabetes, and enable clients who are potentially at risk of developing these conditions to have timely access to health services and interventions. The interventions were derived from the harmonisation of best practices across various institutions and settings, including Institute of Mental Health (IMH), and community and primary care providers.
SERVING OUR POPULATION
As at December 2020, the NHG Community Nursing team comprised 85.5 registered nurses and 32 lay extenders (or community care associates):
- The team served more than 15,000 unique clients in the Central zone, and some 13,000 unique clients in the Yishun and Woodlands zones collectively.
- Community nursing programmes rolled out include the Community Nursing Pilot Programme, Ageing-in-Place Community Care Team (AIP-CCT), Hospital-to-Home (H2H), Community Health Post (CHP-Health Coach), Community Health Team (CHT-Nursing and Health Coaches), Community Screening (P5, Functional Screening), Project CARE, Coaching for Health Action and Management Programme-CHAMP (CHP), and Programme IMPACT.
- The team managed 114 Community Nursing Posts (CNPs) co-located at Senior Activity Centres (SACs), Residents’ Committees (RCs), Community Centres (CCs), etc.