Communities o​f Care and Connectors

Yishun Health (YH) is committed to building of Communities of Care (CoC) with you, our community partners and resident groups. CoC is a network of partners working together to enable community-based care and meet the needs of our residents.​

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YH’s Regional Teams cover six regions across Yishun and Sembawang. Our teams of nurses and connectors provide residents with the skills, tools and links to self-manage and render mutual help to each other in:

• Checking blood pressure, blood sugar, height and weight.
  
• Learning about healthy lifestyle choices.
  
• Building a personalised care and support plan, and signposting to community support to live well with their long-term conditions.
• ​Addressing questions on medications, risk of falls, memory loss, community resources and programmes.
  

Connectors are community-based professionals who support residents to navigate and connect with local resources to improve their well-being. Connectors are also trained to support residents in developing care plans to manage and improve their health.

Together with our community partners, resident groups and YH, you can be a part of our community of care in the North to support our residents!


For residents​ able to self-help


Share these resources to connect them:

 




• Islandwide - Encourage them to search for programmes on Healthy 365 App.
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• Yishun & Sem​bawang - scan the QR code to find out more or click here!​

For residents who need support to navigate and explore

Please partner with us to:​

• Display posters in your clinic with your unique QR code that links with our Regional Team
  
• ​ ​Share flyers for interested residents to consider
  
• Encourage residents to walk into a Commu​nity Health Post​​​​ or​​​
  
• Encourage residents to connect with our Regional Team​​​
  



 Example of a poster to be displayed at your clinic


Contact us at pco@nhg.co​m.sg​ to enquire or come on board!​

Community health teams and Community Health Posts (CHPs)

WH is committed to building Communities of Care (CoC) in collaboration with health and social service providers in the community, to deliver integrated care and support to our residents.

Through our Community Health Posts (CHPs) and partners' spaces located in the neighbourhood, our Community Health Teams (CHTs) comprising of community nurses and health coaches, support GPs in their care for residents who require community support to address their lifestyle and health needs. As a GP, you may utilise the expertise of our CHT to support your residents in:

• Planning their health journey and setting goals
  
• Managing their chronic health conditions
• Participating in exercise and wellness programmes
  
• Connecting with community resources, activities and care services​
  

You may refer your patients to the nearest CHP. We can empower residents to better manage their health and chronic conditions by working together.

Scan here or click here to find out more about our CHPs locations and operating hours

Developed and conducted by our Health Coaches, our Community Wellness Programmes are designed based on resident’s health level and goals. Examples of current programmes available are:​

1. FitterLife (Weight Management​)

FitterLife is a 12-week healthy weight management programme that aims to empower participants to take charge of their weight management through lifestyle habit modifications, healthy eating and exercise.

The programme emcompasses the following components:

• Comprehensive health education which includes nutrition, mindful eating and stress management
  
• ​Ongoing group engagement and conversations on goal setting to motivate participants towards long-term healthy lifestyle habits
  
• ​Physical exercises tailored to individual fitness levels
  

• The programme is suitable for individuals aged 18 to 64 years, who do not have chronic conditions and with a BMI ranging from 23.0 to 37.4kg/m². Should your residents not meet these requirements, you may refer them to our CHT who can recommend alternate weight management programmes or activities suited to their needs.
  

2. CommFit (Frailty Prevention and Management​)​​

CommFit is a six-month long frailty prevention and management programme designed for pre-to moderately- frail residents. The programme aims to reduce the adverse effects associated with frailty, such as falls, functional decline and frequent hospital admissions. This is achieved through targeted interventions and promoting sustained healthy lifestyle habits in close collaboration between participants and our CHT.

The programme encompasses the following components:​

• ​Comprehensive frailty assessment to develop a personalised intervention plan for each participant
  
• Exercise and nutrition advice and coaching to establish health goals, develop action plans and monitor progress towards the achieving health goals
• Caregiver education and support to equip caregivers with essential knowledge to support their loved ones
  
• Medication review by community nurses to improve medication management
  
• ​Home environment assessment to identify potential fall hazards
  
• ​Referral to relevant services based on specific needs
  

This programme is suitable for seniors aged 55 years and above with Clinical Frailty Scale scores ranging from 4 to 6, and/or individuals who present with fall risks. ​

​3. Advance Care Planning (ACP)​

WH collaborates with partners to raise awareness of ACP within the community, to empower individuals to plan for their future health and personal care. This approach ultimately leads to better patient-centred care. WH aims to initiate ACP earlier and to make ACP more accessible by extending it beyond hospitals to the community.

Recognising that ACP is an integral component of holistic care provided by family doctors, WH extends the following support to GP partners to equip your team with the necessary skills for meaningful ACP conversations with your residents:

• ​ACP Referral Programme: GP and community partners who wish to refer residents interested in documenting their ACP can participate in this programme. Published ACPs will be made available through the NEHR system.
  
• ​ACP Trainings: WH provides ACP trainings for GP and community partners who are interested in enhancing their staff in ACP advocacy or facilitation (General ACP/Preferred Plan of Care). We strongly encourage the involvement of the resident’s primary care team in these important conversations as part of relationship-based care.
  • ​ACP advocacy training is suitable for individuals, such as clinic assistants, centre managers, outreach and engagement staff.
  • ​ACP facilitation training is designed for doctors, nurses, social workers, and allied health professionals. ​

4​. CONNACT Plus (Knee Osteoarthritis Management) - Upcoming

CONNACT Plus is a community-based programme designed to optimise rehabilitative outcomes for patients with knee osteoarthritis, with the goal of reducing and/or delay the need for unnecessary surgery. This programme is delivered collectively by a team of community rehabilitation partners and health coaches.

The programme will provide the following:​

• ​Physiotherapy exercises focusing on improving flexibility, strength and functional activities​
  
• ​Psychoeducation sessions covering topics such as nutrition, pain acceptance and mindfulness
• ​​​​Health coaching to set personalised health goals, develop action plan and monitor progress towards the desired goals

This programme is suitable for residents aged 45 years and above who are experiencing knee osteoarthritis and are still mobile.​

Scan the QR code or click here​ for the latest information about WH’s services and integrated care programmes.	Scan the QR code or click​ here to make a referral to our CHT or integrated care programmes.
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