O u r A g e i n g Po p u l a t i o n : F r a i l t y a s a C o r n e r s t o n e o f H e a l t h & S o c i a l C a r e

FRAILTY MEETS STRENGTH IN THE COMMUNITY

Keep healthcare sustainable & affordableSupport aspirations & needs of the Merdeka Generation

Enhance CHAS

Extend MediShield Life coverage

Enhance community care and caregivingStrengthen primary care foundation

Build communities of care to support ageing in place

Empower Singaporeans to live healthilyManage diabetes

Encourage screening

Support women’s health

Strengthen community mental health services

Equip professionals and providersA progressive, future-ready workforce to meet demand

Adapted with permission from A/Prof Ian Leong, NHG Clinician Lead, Living with Frailty, Mar 2019

Front door(ED/Call Centre)

Inpatient Transit Community (Home)

Primary Care (GPs & Polyclinics)

Specialist Outpatient

Clinic

Intermediate Care Clinic

Primary Care engagement & collaborative programmes

Community Hospital

Nursing Home

Frailty-Ready System of Care

Frailty-Ready Transitions

AH-Nursing Home Flows

Frailty-Ready Community

Ambulatory Care for the Frail

Frailty-Ready Whole Hospital

© Copyright 2018 National Healthcare Group, Singapore. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any way, for or by any means electronic or mechanical, including photocopying, recording or otherwise, without the prior permission of the National Healthcare Group.

MANDAI

SIMPANGWOODLANDS

9

ANG MO KIO11

SERANGOON

8 HOUGANG

9BISHAN15

TOA PAYOH18

GEYLANG

7NOVENA-ROCHOR-KALLANG

13

SEMBAWANG4

YISHUN

7

760115

760131

400003

805910

737878

757614

520718

319264

760765

761426

521117

090007

521827

670629

730123

768992

760260

731569

460012

338771

320128

219458

520237

560113

670139

N

N

123456

Number of Community Health Posts

Number of Community Nurse Posts

Share a Pot® site

Population Health Improvement in the Community

Existing groups§ Faith-based§ Centre-based

Group activities to promote health & wellbeing

NEW!§ Identification § Outreach

Block mapping, screening activitiesJoint outreach & management

Last mile deliverySOCIAL

Social engagementPeer group support

HEALTHSteady: Falls, BalanceLean: DiabetesStrong: Frailty

Peer

sup

port

for

chro

nic

dise

ase

Coaching

Supported self-managem

entSkills for life

Inclusive community

Teams are § placed-based§ multi-disciplinary§ self-managed

Stealth health

Collaborative partnerships

Illustrated figures created by Lluisa Iborra from Noun Project

Discover, Activate, Connect, AppreciateCitizens as the Primary Unit of Health/Well-Being Production

ABCD

Neighbourhood conversations & visionStrong networks built on relationships

Increasing the “BY” space

Community maps

What can the residents do for

themselves without outside help?

What can they do with a little outside help?

What do they need to be done

for them?

DONE BY THEM DONE WITH THEM DONE FOR & TO THEM (WITHOUT THEM)

Asset-Based Community Development (ABCD)

PMHx§ Diabetic Mellitus§ Hypertension§ Hyperlipidemia§ Stable left lower limb

peripheral artery disease§ Coronary artery disease§ Major depressive disorder Appointments§ SOC PSY§ SOCVascular§ Polyclinic

1. Glipizide 15MG BD2. Metformin 750mg BD3. Sitagliptin 100mg OM4. Amlodipine 5mg OM5. Losartan Potassium 75mg OM6. Atorvastatin 80mg ON7. Carvedilol 12.5mg BD8. Plavix 75mg OM9. Omeprazole 20mg BD10.GTN 500mcg PRN sublingual11.ISMN 60mg OM12.Amitriptyline HCl tablet 10mg ON13.Glucosamine Sulphate 1000mg OM14.Bisacodyl 10mg PRN15.Lactulose 10mls TDS PRN16.Vitamin D3 1000unit OM

Mdm A, 69 Y/O, Chinese§ BADL & IADL

independent§ Community ambulant § CFS 4 § Stays with husband in a

one-room rental flat § Shifted to Yishun in 2017§ Referred by TOUCH SAC

OUTCOMES OF INTERVENTION1. Reduced and simplified medications2. Adherent to medications3. Followed dietary recommendations4. Regular exercise5. Followed care plan

§ Improved BP & DM control§ Ideal BMI§ Better mood

6. Single polyclinic appointment7. Familiar with community resources8. Volunteer at CNP & SAC

Case Study: Five Capacity & Capability Building Thrusts for Self Management

Health coaching Group activities to promote health &

wellbeing

Peer support for people living with

chronic disease

Supportedself-management

Asset-Based Community

Development

Case Study: Five Capacity & Capability Building Thrusts for Self Management

Mdm Lim Peck GeokFrail

Broke her arm after colliding with a passerby, protective family insisted that she stayed home & wore her arm brace >6 months. Encouraged by neighbour’s daughter to join Stepping Up workshop at Wellness Kampung to manage her frailty.

Mdm Chua PongCoronary heart disease

Neighbour of Mdm Lim; daughter is a Kampung Buddy who brings her to the Wellness Kampung everyday. Participates in daily exercise and has friends around her while her daughter is out doing Meals-on-Wheels visits.

Mdm Chang Yuen Ling Frail

Residents noticed her BMI dropping during Share A Pot®. Aunties at the Wellness Kampung look out for her by cooking food that she enjoys. SMART Nurses now monitor her nutrition.

Mdm Tan Ah MoyEarly dementia

aka “The Supervisor” of the group, coordinates activities of the day for the rest of the “Cover Girls.” The rest of the aunties look to her for “guidance.”

Community Capacity- & Capability-BuildingSeniors Looking After Seniors: Wellness Kampung Cover Girls

Web of SupportIt takes a village to age well in place…

Social Relationships and Mortality Risk: A Meta-analyticReviewJulianne Holt-Lunstad1.*, Timothy B. Smith2., J. Bradley Layton3

1 Department of Psychology, Brigham Young University, Provo, Utah, United States of America, 2 Department of Counseling Psychology, Brigham Young University,

Provo, Utah, United States of America, 3 Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America

Abstract

Background: The quality and quantity of individuals’ social relationships has been linked not only to mental health but alsoto both morbidity and mortality.

Objectives: This meta-analytic review was conducted to determine the extent to which social relationships influence risk formortality, which aspects of social relationships are most highly predictive, and which factors may moderate the risk.

Data Extraction: Data were extracted on several participant characteristics, including cause of mortality, initial health status,and pre-existing health conditions, as well as on study characteristics, including length of follow-up and type of assessmentof social relationships.

Results: Across 148 studies (308,849 participants), the random effects weighted average effect size was OR = 1.50 (95% CI1.42 to 1.59), indicating a 50% increased likelihood of survival for participants with stronger social relationships. This findingremained consistent across age, sex, initial health status, cause of death, and follow-up period. Significant differences werefound across the type of social measurement evaluated (p,0.001); the association was strongest for complex measures ofsocial integration (OR = 1.91; 95% CI 1.63 to 2.23) and lowest for binary indicators of residential status (living alone versuswith others) (OR = 1.19; 95% CI 0.99 to 1.44).

Conclusions: The influence of social relationships on risk for mortality is comparable with well-established risk factors formortality.

Please see later in the article for the Editors’ Summary.

Citation: Holt-Lunstad J, Smith TB, Layton JB (2010) Social Relationships and Mortality Risk: A Meta-analytic Review. PLoS Med 7(7): e1000316. doi:10.1371/journal.pmed.1000316

Academic Editor: Carol Brayne, University of Cambridge, United Kingdom

Received December 30, 2009; Accepted June 17, 2010; Published July 27, 2010

Copyright: ! 2010 Holt-Lunstad et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permitsunrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Funding: This research was generously supported by grants from the Department of Gerontology at Brigham Young University awarded to JHL and TBS andfrom TP Industrial, Inc awarded to TBS. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing Interests: The authors have declared that no competing interests exist.

Abbreviations: CI, confidence interval; CVD, cardiovascular disease; OR, odds ratio

* E-mail: julianne_holt-lunstad@byu.edu

. These authors contributed equally to this work.

PLoS Medicine | www.plosmedicine.org 1 July 2010 | Volume 7 | Issue 7 | e1000316

© Copyright 2018 National Healthcare Group, Singapore. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any way, for or by any means electronic or mechanical, including photocopying, recording or otherwise, without the prior permission of the National Healthcare Group.

You think because you understand “one” that you must therefore understand “two” because one and one make two. But you

forget that you must also understand “and”.Sufi teaching story

Dr Wong Sweet FunSenior Consultant, Geriatric Medicine

Deputy Chairman, Medical Board (Population Health)Clinical Director, Population Health & Community Transformation

Chief Transformation OfficerClinical Director (Population Health)

Clinical Lead, Living Well

Khoo Teck Puat HospitalKhoo Teck Puat Hospital & Yishun HealthKhoo Teck Puat Hospital & Yishun HealthKhoo Teck Puat Hospital & Yishun HealthWoodlands Health CampusNational Healthcare Groupwong.sweet.fun@ktph.com.sg