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Population Health


Population Health Perspectives

NHG aims to meet the current and future challenges of population ageing, increased chronic disease burden, a surge in Frailty, and rising demand for healthcare in an effective and efficient manner. Our River of Life framework provides a blueprint for our population health endeavours. It encompasses the whole population – from the robust, to people with chronic diseases who are managed in the community, to individuals who develop complications from chronic diseases, to those who require Crisis and Complex care, and finally, the terminally ill.


SOME CHALLENGES WE FACE IN POPULATION HEALTH…

“We need to move towards proactive and preventive care, strengthening capabilities in the community to enable independent living, and boosting Primary Care services to help our population to manage their chronic illnesses effectively. Our hospitals have moved beyond acute care to a more holistic approach of working with our health and social partners in the community to ensure that our patients and their caregivers are well-supported. For those who are admitted to the hospital, we will manage them appropriately, and aid them in their transition back to their homes or to the community as seamlessly as possible. We are acclimatised to working in the comfort of the hospital where everything, especially services and infrastructure, is in place and within reach. However, we must determine how we can work in the community, in a different, unfamiliar setup from the hospital environment. This means crosstraining our staff to not just focus on existing skills but to be trained in other skills as well.”

PROFESSOR PANG WENG SUN
Deputy Group CEO (Population Health),
NHG


ENVISIONING POPULATION HEALTH AS A RIVER OF LIFE...

“NHG’s population health strategy, which is essentially the River of Life framework, details how we partner our patients throughout the different stages of life. The River of Life is divided into Five Segments of Care – Living Well, Living with Illness, Crisis and Complex Care, Living with Frailty, and Leaving Well – underpinned by strong Primary Care and mental health services. We have segmented our population into three zones, namely Central Health, Yishun Health and Woodlands Health, to create a continuum for healthcare delivery and to provide an integrated holistic care system for our patients. This requires a network that goes beyond the hospital to the community. Our population health approach is to work with our patients and their caregivers to enable them to manage their own health, and to change the role of our healthcare system from “provider of care” to “partner in care”. I believe this would drive and support more sustainable changes in people’s behaviours and health outcomes.”

DR WONG KIRK CHUAN
Chief Operating Officer (Population
Health), NHG & Chief Operating Officer,
Woodlands Health Campus


WHAT IT MEANS TO LIVE WELL...

“Everyone wants to live well. Most of us think that we are living well if we are not frail or dying, and do not have a disease. The truth, however, is that all of us wish to live well at every stage of our lives, be it while we are afflicted with illnesses or at the end of life. As healthcare providers, we should be in the community to help our patients live well by improving their physical and psychosocial environment, socia lsupport, and equipping them with skills to care for themselves and each other. Certain concepts, such as Living Well and Frailty, can be difficult to comprehend and explain. Thus, we decided to weave these notions into the everyday programmes of our residents. If everyday decisions are healthy decisions, the end result would be healthy individuals. Hopefully, people living under NHG’s purview will be healthy even before our help is enlisted. In the event the occasion arises, we will be able to provide them with not just the treatment, but the skills to continue their treatment at home.”

DR WONG SWEET FUN
Chief Transformation Officer & Deputy
Chairman Medical Board (Population
Health), Yishun Health


THE ROLE OF PRIMARY CARE...

“As the cornerstone of our healthcare system, Primary Care will play an even bigger role by continuing to integrate and coordinate care. As healthcare becomes more community-oriented, the individual has a bigger part to play. As we transform health, we must work with social care partners, our patients and their caregivers to build relationships founded on trust. We have to empower our population, and engage them in self-awareness and self-management of their health so that they can embark on behavioural changes that will lead to healthier lifestyles. NHGP will continue to actively engage and collaborate with our GPs in the Central-North Primary Care Network (PCN). Innovative practices such as Tele-collaboration and Telemedicine help to integrate care and facilitate our community’s reach to health services.”

DR KAREN NG
Director, Clinical Services,
National Healthcare Group Polyclinics


THE VISION FOR THE FUTURE OF CRISIS AND COMPLEX CARE...

“We have developed a very robust acute hospital system. Within the hospital system, we need to ensure that the body of work that we do is standardised and delivered at low cost, and produces high value outcomes. Increasingly, we are moving into coordinated care. We are urging specialists to think beyond their fields, and look into other needs of the patient. There is significant value in this practice – not just to the cost of care delivery, but to what really matters to the patient. We need to treat patients much earlier to prevent the disease from progressing in order to reduce the cost of treating complications, unfavourable outcomes and treating the sequela ramifications of diseases. To enable this, we have to work closer with our Primary Care partners. We also have to integrate complex care, not just along and across disciplines and settings, but also in the community.”

ASSOCIATE PROFESSOR THOMAS LEW
Group Chief Data and Strategy Officer
NHG


WHAT IT TAKES TO FIGHT FRAILTY…

“As a person grows older, he or she accumulates more deficits in terms of illnesses, and thus becomes frail. Hence, an individual who does not take care of his or her health can become frail at a much younger age. While there have always been initiatives to address Frailty, what we want to do now is to integrate all the best initiatives from our different stakeholders to help manage the condition as well as possible. As a care provider, we can influence and provide the science behind what people should do. At the individual level, we are talking about behavioural change, such as adopting a healthy lifestyle to slow the progression of Frailty. At an organisational level, there needs to be a cultural change in how organisations can unite and work better as an alliance of providers to care for individuals who are frail. At a social level, we need to be more kampung-like as a country so that our communities become more used to taking care of people who are frail.”

ASSOCIATE PROFESSOR
IAN LEONG
Clinical Director,
Division of Central Health


HELPING OUR PATIENTS TO LEAVE WELL...

“Leaving well, or to live well until End-Of-Life, means helping a patient diagnosed with a life-limiting condition to better understand his or her condition, the disease trajectory, and what to expect in the coming months or the next few years. At this stage, it is important to help our patients sort out the issues in their lives, be they psychological, social, or spiritual, so that they can have proper closure before the end of life. Finally, in the terminal stage, they must be well-supported and cared for in their preferred place of care and death. With Advance Care Planning (ACP), we will note their preferences in the event of deterioration and bring in the right resources to support them. We are now trying to actively train more ACP facilitators who can initiate these conversations when suitable patients are identified. Presently, we are trying to reach out to different touch points, not just to hospitals and polyclinics, but also to Family Service Centres.” 

ASSOCIATE PROFESSOR WU HUEI YAW
Senior Consultant,
Department of Palliative Medicine,
Tan Tock Seng Hospital


SHIFTING CARE BEYOND HOSPITAL TO COMMUNITY…

“Tan Tock Seng Hospital (TTSH) as a key member of Central Health plays a critical role to enable care to shift beyond the hospital into the community. This will enable our hospital to reduce emergency attendances, hospital readmissions, and length of stay. As the anchor hospital for the central zone, TTSH continues to develop new tertiary care capabilities to deal with specialised care requiring deep expertise, and multidisciplinary care of complex conditions. We work closely with other hospitals in NHG in service development, knowledge transfer, research, and education. Situated in Novena Medical Hub, TTSH is also well-positioned to drive NHG’s academic partnerships with LKCMedicine and other tertiary education institutions. A key focus for TTSH will be in healthcare innovation and workforce transformation through the Centre for Healthcare Innovation (CHI) Co-Learning Network.”

PROFESSOR EUGENE FIDELIS SOH
CEO, Tan Tock Seng Hospital
& Central Health


REINVENTING HEALTHCARE FOR THE FUTURE…

“As the first hospital in Woodlands, Woodlands Health Campus (WHC) will care for some 600,000 future residents in the North. Our 7.66 hectare site will comprise a fully integrated Acute and Community hospital, specialist Outpatient Clinics, as well as Intermediate and Long-Term Care facility. This is the first time all facilities are conceptualised and built simultaneously, providing a rare and precious opportunity to innovate. WHC aims to reinvent the way care is delivered. The Campus will incorporate SMART technology to enhance care within and beyond hospital walls. As the team envisions the future of care, we are also pacing for the present, by ensuring facilities and services give thoughtful consideration to the current needs of our elderly patients and caregivers.”

DR JASON CHEAH
NHG Deputy Group CEO (Transformation),
& CEO, Woodlands Health Campus


INCULCATING QUALITY IMPROVEMENT…

“The spirit of continuous improvement (Kaizen) is part of our Yishun Health DNA. We all have two jobs – the first is to do the job; the second is to make continuous improvements to the job. We adopt a Thinking, Doing and Learning mindset from the small to the big things we do, to make healthcare ‘Better, Faster, Cheaper, and Safer’ for all.”

MRS CHEW KWEE TIANG
CEO, Khoo Teck Puat Hospital
& Yishun Health


WORKING TOGETHER TO IMPROVE MENTAL HEALTH…

“I help my young patients manage their feelings. I save lives, one feeling at a time. Many cases are now managed by school counsellors and our community partners, and this is heartening because it shows everyone working together to combat mental illness.”

ASSOCIATE PROFESSOR DANIEL FUNG
Chairman Medical Board,
Institute of Mental Health


ADVANCING DERMATOLOGICAL CARE IN THE POPULATION…

“The new National Skin Centre (NSC) facility will be an integrated hub that offers a full spectrum of subspecialty expertise to treat patients with complex skin diseases, while providing an optimal environment to galvanise educators and students in learning, and to support and advance clinical research.”

ASSOCIATE PROFESSOR TAN SUAT HOON
Director, National Skin Centre


FINANCE TRANSFORMATION IN HEALTHCARE…

“At NHG, we are in the process of changing the way consumers pay for healthcare in order to achieve cost sustainability and better care value. It involves adopting value-based financing methods that drive changes in behaviours of healthcare providers, which are expected to enhance care efficiency and productivity. There will be a focus on care segments where healthcare cost will rise more acutely, but which  are also more amendable to quicker cost-bending interventions. Our ultimate aim is to optimise and drive healthcare cost down, and help build a long-term sustainable and affordable public healthcare system for Singapore.”

MS LIM YEE JUAN
Group Chief Financial Officer, NHG