Our programmes are designed to cater to the different care needs of our population. This approach allows individuals to receive the appropriate care, and also gives us the ability to deploy resources efficiently and effectively to meet individuals’ needs.
Health Screening and Lifestyle Education
This programme focuses on health education, early detection of chronic diseases and timely interventions in those aged 40 years and above, in order to prevent the development of chronic diseases such as diabetes or hypertension, or to slow down the progression or deterioration of such diseases.
This is achieved through targeted health screening programmes for the community with referrals to appropriate interventions based on screening results.
Our health screening programmes are currently available at our partner GP clinics, Frontier Family Medicine Clinic and polyclinics (Bukit Batok, Choa Chu Kang, Clementi and Jurong) in the western region of Singapore.
Appropriate-Siting of care
This programme involves the appropriate siting of care for patients who are medically stable and do not require specialist care from NUH to our pool of primary care partners in the community.
These patients can thus have their care transitioned seamlessly from NUH specialist outpatient clinics to our primary care partners in the community.
Patient-Appointment Consolidation (PAC)
The aim of this programme is to streamline care for individuals with multiple chronic conditions and who are seen by two or more specialties in NUH Specialist Outpatient Clinics.
Patients with multiple chronic conditions can have their appointments consolidated so that they are taken care of by ONE primary physician.
The PAC programme allows for patients with multiple chronic conditions to be cared for by a dedicated physician, who will manage all his chronic conditions holistically. This physician can either be a family physician from one of our primary care partners or a specialist from NUH.
Under this programme, the primary physician will manage the patient holistically, with inputs from other specialists in NUH as needed. The physician will also be supported by a multi-disciplinary team of nursing and allied health professionals in managing the patient.
NUHS Transitional Care Programme
This programme aims to enable patients to transit smoothly from the hospital to their home by having a team of doctors, nurses and allied health professionals who will provide continued care in the comfort and privacy of the patient’s home. The Transitional Care team will first assess the patient’s needs prior to discharge from hospital, after which a personalised care plan will be designed based on the patient’s needs. The care plan could include education for patients and/or caregivers, medication management and referral to appropriate community resources.
NUHS-RHS Integrated Interventions and Care Extension (NICE) Programme
This programme aims to provide patients with frequent readmissions to NUH (at least 3 or more admissions in a year) with holistic and integrated case management and care coordination, so as to improve their quality of life and quality of care.
A dedicated case manager will be assigned to each patient and will work with the patient’s primary physician to develop an individualised care plan that will holistically address the patient’s medical and social needs. The case manager will serve as the patient’s main point of contact for assistance in navigating and receiving care from the necessary medical and social services in the hospital and community.