TTSH Community Health Teams Our Journey in Managing Frequent - - PowerPoint PPT Presentation

TTSH Community Health Teams

Our Journey in Managing Frequent Admitters

2008 2012

Post-Acute Care @Home

• Rehabilitate and monitor patients

with assessed clinical or nursing need post-discharge

• Promote caregiver competence in

managing homebound patients

Aged Care Transition

• Complex care coordination
• Ease transitions of patients back to

the community and prevent readmissions

Virtual Hospital

• Targeted at frequent admitters (FAs)

i.e. has 3 or more admissions in the past 1 year

• Reduce unnecessary hospital bed

days and emergency attendances

2016

Transitional Care Service

• Single-point-of-contact to coordinate

the care plan of patients with complex care needs

• Support safe and coordinated

transitions from the hospital to the community and home

2018

Community Health Teams

• Population health focus
• Managing the pre-frail to frail

Transitional Care within the RHS Tripartite Framework for Care Coordination

The TTSH Community Health Team works closely with Community Partners, who will help the patient navigate the services in the community, and also establish GP & Primary Care support for the patient.

Crisis Frailty Dying Well Well Illness FMC GP Polyclin ics

PATIENT

Community Health Team Community Partners Primary Care Community Health Team

ACTION CC VH Health Manager PACH P1 P2

ACTION

CENTRAL ZONE DEMOGRAPHICS

Oldest Population of 17% aged 65y & Above (13% Nationally) 53% of Inpatients aged 65y & Above (29% Nationally) Largest Population Catchment of 1.4M (26% of 5.54M)

Central, 65y & Above, 17 Yishun, 65y & Above, 10 Woodland s, 65y & Above, 8

% Population ≥65 Yrs

Central Yishun Woodlands

Why the Move Towards Population Health?

ROLE OF COMMUNITY HEALTH

To ensure and maintain the well ll-being of the Cen Central Health res resid ident popu population, keeping them well in the community and minimizing healthcare resource utilization.

Ang ng Mo Ki Kio Bish shan Sera erango goon Houga gang Ge Geyl ylang No Nove vena-Kallang- Ro Roch chor

• r

Toa

• a Payo

yoh NHG Central Zone

• Primary Care*
• Community Partners*

*Note: Locality-Based

• Activated Residents*

3 Aspects of Well-Being

• Health
• Social
• Mental

Our Three-Pronged Strategy

• Service provision
• Collaboration
• Activation

The Community Health Framework (within Sub-Zones)

Hospital Community

Discharges

ED SOC Inpatient

• Comm. Care Prog.
• Comm. Nursing/

H2H

COMMUNITY HEALTH TEAM

Value Stream Mapping and Process Improvement

• SGA
• CNS
• CHPs
• VWOs

Community-Based

• CHs
• NHs
• Hospices

Institution-Based

COMMUNITY PARTNERS The Community Health Eco-System

CRISP Empanelment Primary Care Networks

• GPs
• FMCs
• Polyclinics

Primary Care

PRIMARY CARE PARTNERS

• CHA

Activated Residents

Project Care Project Dignity Programme IMPACT

Hands off means a change in primary provider in a Community Of Providers MY Patient OUR Patient Understand the needs of the current unenrolled; think of how to meet these needs “ENROLLED” Population WHOLE Population Centre is our “base”; but care delivery can be anywhere To understand the different ways

• f affecting the environment & its
• ccupants

CENTRE Focused COMMUNITY Focused Shifting of focus: From services provided by TTSH to how we can work together to meet all needs in a coordinated manner Delivery of SPECIFIC Services Meeting ALL Needs in Integrative Ways

What We Hope to Be Different With Community Health

Bu Building re rela latio ionship ips and wor workin ing wi with loc

• cal part

rtners across health care and social care domains to enable healt lth engagement, care re coo

• ordi

rdinatio ion and ageing-in in-pla lace.

Community Health Team

7

Place-based, multi- disciplinary* teams embedded in each zone

*Comprising doctors, nurses, allied health professionals, pharmacists and medical social workers

Community Health Team

OBJECTIVE OF THE COMMUNITY HEALTH TEAMS

To build re rela latio ionship ips and wor work wi with th loc

• cal partn

rtners across health care and social care domains to enable healt lth engagement, care re coo

• ordi

rdinatio ion and ageing-in in-pla lace.

Delay Frailty Progression Empowering Self- Management of Health Issues Management of Acute Medical Conditions Case Management

Primary focus of Community Health Teams

Service Provision

• Risk assessments
• Case management
• Coaching, education, counselling
• Promoting self-empowerment
• Bridging interventions

Collaboration

• Case discussions
• Co-management
• Care transitions

Activation

• Co-creation of programmes
• Co-learning of best practices
• Create activated communities

Direct Service Provision

• Home visits
• Telephone reviews
• Site clinic reviews at Community

Health Posts Collaboration & Activation

• Development of interest-based

programmes for residents

• Falls screening with partners
• Group education and coaching
• Training for partners

Bu Building re rela latio ionship ips and wor workin ing wi with loc

• cal part

rtners across health care and social care domains to enable healt lth engagement, care re coo

• ordi

rdinatio ion and ageing-in in-pla lace.

Community Health Team

Ho How Our r Tea eams Work

Referral form

THANK YOU