SINGAPORE – Ng Teng Fong General Hospital (NTFGH) is strengthening support for patients with complex needs beyond the hospital through its Care Connect Hub, a hospital-based programme that provides structured post-discharge coordination for patients with complex chronic conditions.
On 16 August 2026, NTFGH formalised a partnership with Loving Heart Multi-Service Centre (Loving Heart) through a collaboration agreement signed during Loving Heart Community Day, with Ms Grace Fu, Minister for Sustainability and the Environment and Minister-in-charge of Trade Relations, Grassroots Adviser for Jurong East-Bukit Batok GRC, in attendance.
Under the partnership, volunteers from Loving Heart who have been trained as Community Carers will assist selected high-risk patients living in the Jurong East vicinity, identified through the Care Connect Hub, thereby extending care beyond the hospital and into the community.
When hospital discharge is just the beginning
As Singapore's population ages and the burden of chronic diseases continues to grow, more patients are living with complex chronic conditions such as kidney, heart and liver failure. While these patients are medically stabilised before leaving hospital, many experience preventable deterioration after discharge due to limited social support, low health literacy, poor adherence to medication or lifestyle advice, and delays in seeking help.
At NTFGH, a review identified approximately 6,670 patients living with kidney, heart or liver failure. Among NTFGH patients who were readmitted within one year, 68% experienced at least one unplanned readmission within 60 days of discharge, due largely to inadequate social support as well as poor adherence to medication and appointments.
A trial conducted by NTFGH between November and December 2025 found that many discharged patients with complex needs benefitted from structured post-discharge follow-up. The trial also demonstrated the value of structured outreach in identifying unmet social needs early and connecting patients with appropriate support before their conditions worsened. Among 200 patients who received structured post-discharge follow-up, the 60-day re-admission rate was reduced from 40% to 31%.
A coordinated model bridging hospital and community
Supported by the JurongHealth Fund, the Care Connect Hub will run as a two-year pilot from 2026 to 2028. Established to integrate a structured approach to social risk screening, post-discharge follow-up and community support into the hospital’s discharge process, the programme is built on a clinically governed care model that brings together healthcare professionals, experienced retired nurses serving as Care Connectors, and trained Community Carers to strengthen continuity of care beyond hospital discharge.
Over the pilot period, the Care Connect Hub aims to reach approximately 1,000 high-risk patients across the western region by identifying social and health risks early, facilitating timely referrals to healthcare and community services, and helping patients stay well at home.
Care Connectors
Experienced retired nurses will join the Care Connect Hub as Care Connectors, where they will:
Loving Heart Community Carers
Loving Heart is a social service agency (SSA) in Yuhua. Its Community Health Department, headed by a Care Clinician, has been training Community Carers to serve the needs of frail elderly in the community including those discharged from the hospital.
While hospitals and community services each play an important role, Community Carers fill an important gap by providing consistent, relationship-based support to vulnerable patients in the place they need it most – their own homes.
Under NTFGH’s collaboration with Loving Heart, the programme will train 25 Community Carers to assist patients requiring more sustained support in the community. The National University Health System (NUHS) Community Care Team and NTFGH nurses have jointly developed a training programme which equips Loving Heart’s Community Carers with practical skills tailored to support patients with complex chronic conditions such as organ failure.
Community Carers will reinforce care plans through regular home visits, through which they will conduct:
Operating strictly within non-clinical roles and guided by standardised protocols, they will escalate concerns promptly to the NUHS Community Care Team or Loving Heart, ensuring all clinical decisions remain firmly with healthcare professionals. This model of care harnesses the power of the community while ensuring patient safety remains paramount.
Looking ahead
Building on the pilot, NTFGH plans to broaden the Care Connect Hub's reach through partnerships with more Active Ageing Centres across the western region, enabling more patients to benefit from coordinated post-discharge support closer to home.
The hospital also intends to explore extending the Care Connect Hub to other patient groups with similar care continuity and adherence needs, including individuals living with frailty, so that more vulnerable patients can receive timely support before avoidable deterioration occurs.
Strengthening care beyond the hospital
Associate Professor Dan Yock Young, Chief Executive Officer, NTFGH and Jurong Community Hospital, said: "As healthcare needs become increasingly complex, supporting patients well requires care that extends beyond the hospital.
The Care Connect Hub helps patients recover more confidently at home while reducing avoidable hospital readmissions.
At the same time, it reinforces our healthcare workforce by creating meaningful opportunities for retired nurses and Community Carers to contribute alongside our healthcare teams, building a stronger and more connected system of care for the future.”
Professor Teng Su Ching, President of Loving Heart, said: “Loving Heart is grateful for the opportunity to collaborate with NUHS and NTFGH. We have always believed that the community has a very significant part to play in the healthcare delivery ecosystem. This gives the Community Carers purpose and personal growth and in time, the community as a whole will become more resilient.”
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