Building Self-Supported Community Ecosystems Self-Supported Community... · 2018. 11. 23. · •...
Transcript of Building Self-Supported Community Ecosystems Self-Supported Community... · 2018. 11. 23. · •...
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Building Self-Supported Community Ecosystems Mr Lau Wing Chew
Chief Transformation Officer, WHC
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Members of National Healthcare Group
• Opening from 2022 • Comprises of a General Hospital,
Community Hospital , Specialist Outpatient Clinic and Nursing Home
• Up to 1800 beds
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CAMPUS OVERVIEW
Northwest aerial view of Woodlands Health Campus
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Woodlands Health Campus Mission Statement
Everything we do is about caring for
and improving the lives of our patients, community and healthcare family.
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Our Community Mission
To create self-supported ecosystems to empower our community to manage their
health and age in place – building a resilient population and a thriving community.
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Woodlands & Sembawang Towns (URA Master Plan 2014)
329,910 RESIDENTS (excluding non-residents)
Setting in the North
YOUNGER Age ≥ 65 years old WDL + SBW: 7.5% National: 11.8%
M O R E M A L AY S & I N D I A N S
WDL + SBW: 32.9% National: 22.4%
HDB DWELLERS
WDL + SBW: 92% National: 80% Source: Population Trends 2014 & 2017
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49% : 51% ratio between those who are aged below 65 and above 65
Top healthcare utilisers in Woodlands & Sembawang Top 20% of patients utilise 84% of healthcare costs Top 5% of patients utilise 57% of healthcare costs
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While the North is younger, proportion of top utilisers with chronic conditions or are frail is comparable to the Central
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Top utilisers of Malay, Indian and Other ethnicities are mostly < 65 years old and has a higher proportion with chronic conditions
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Identification of precincts of interest based on population demographics and
health utilisation data
NHGP
WHC
AdMC
Woodlands Planning Area
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Correlation of social determinants of health to healthcare costs
Source: Montefiore Health System, The King’s Fund 2018
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Community Analysis (Sensing)
Nurses in the Community
(Clinical/Care & Coordination)
CHOPE - Partnership - Volunteers
- Funding (Strengthening)
Community Programs
(Strengthening & Coordination)
Tact
ics
Engage to Understand
Engage for Partnership
(Co-creation, Funding & Volunteers)
Engage for TOMA (Top of mind awareness)
Engage for Collaboration
Stra
tegy
Sense needs & capabilities
Strengthen capabilities of the community
Providing accessible
Clinical/Care touch points Coordinate seamless care
navigation & resources
Go
al
To create self-supported eco-systems, to empower our community to manage their health and age in place - building a resilient population and a thriving community.
Overview of Strategy
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NHGP
WHC
AdMC
Woodlands Planning Area
Sensing through data analytics| Heatmapping
Community Analysis (Sensing)
• Oldest flats • Cluster of rental flats • High socioeconomic needs • High hospital utilisation
• New rental flats and studio apartments • High socioeconomic needs • High hospital utilisation
• Old rental flat and new studio apartments • High socioeconomic needs • High hospital utilisation
• New studio apartment • High chronic disease
prevalence
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Hospital Data
KTPH (2017) • A&E: 3 A&E visits • AH ward: 4 admissions, Total LOS: 43 days • SOC: 1 visit to Cardiology Clinic • YCH ward: 1 sub-acute admission
56 years old Female
High Utiliser
Case Study 1
Sensing through outreach| Building a more holistic view Referred to
Community Nurse for home visit
Community Analysis (Sensing)
Outreach Data
Social • Separated, homemaker • Staying in rental flat with 1
adult son • Does not enjoy living in this
community • Stays at home • Does not exercise regularly • Currently home-bound as her
motorised scooter (obtained for free) is spoilt and not repaired due to cost
Financial • Public Assistance, CHAS • Worried about medical
expenses Self-rated health (scale of 4) • 1 (very poor)
Medical conditions • Diabetes (on insulin) • High Cholesterol • Hypertension • Ischaemic heart disease • Left BKA Follow-up • Woodlands Polyclinic • KTPH Problems with managing health • Appointments – wheelchair-
bound, require taxi • Medication – require son to
prepare medication • Knowledge – cannot
understand doctor’s instructions and explanation without son’s assistance
Interviewer notes: CFS 7
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Hospital Data
KTPH (2017) • A&E: 37 A&E visits • AH ward: 15 admissions, Total LOS: 45 days • SOC: 17 SOC visits (1 Anae, 1 Cardio, 8 Dental, 4 Med, 3 Surg)
51 years old Female
High Utiliser
Case Study 2
Referred to CN for assessment
Sensing through outreach| Building a more holistic view
Community Analysis (Sensing)
Outreach Data
Social • Divorced, unemployed (used
to be a nurse) • Staying in rental flat with
mother and ex-boyfriend • Enjoys living in this
community • Stays at home, Family,
Shopping • Does not exercise regularly • Enjoys cooking, singing, art
and craft, community service Financial • Public Assistance, MFEC • Worried about daily expenses
and housing bills
Medical conditions • Diabetes • High Cholesterol • Liver Cancer • Asthma Follow-up • GP clinic • KTPH SOC Problems with managing health • Appointments • Accessibility to services Interviewer notes: CFS 3 • Cheerful lady though multiple
co-morbidities, manages her conditions well
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Community Assets around Blk 764B Golden Saffron Postal Code
Sunlove Senior Activity Centre 732764
Sree Narayana Mission Senior Care Centre
730861
• NTUC Health Active Ageing Hub • NTUC Health Senior Care Centre
730676
HCA Hospice Care (Woodlands Centre) 730672
CHAS GPs • Banyan Clinic Pte Ltd. • Central 24-Hr Clinic (Woodlands) • My Family Clinic (Woodlands) • Singapore Family Clinic & Surgery • Dr Nah & Lee Family Clinic • Admiralty Family Clinic • Yim Medical Centre (Admiralty)
730768 730768 730768 730717 730780 731678 730678
Care Corner Family Service Centre (Admiralty)
730718
Resident Committee
• Woodlands Zones 5, 6, Sembawang Zone E, G • Woodlands Zones 2, 4 & Sembawang Zones D, H, J
Lighthouse Evangelism Woodlands 738909
Schools • Admiralty Primary School • Evergreen Primary School • Riverside Primary School • Admiralty Secondary School • Evergreen Secondary School
738907 738908 737803 737916 738489
• Woodlands Mart • Admiralty Place • Kampung Admiralty
730768 730678 730676
Admiralty Secondary
School
Riverside Primary School
Admiralty Primary School
Evergreen Secondary
School
Evergreen Primary School
Community Analysis (Sensing)
Sensing for partners| community assets mapping
Natural neighbourhood
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Identifying potential ground partners and spaces
Living environment
Community Analysis (Sensing)
Sensing on the ground| Seeing opportunities and challenges
SARS quarantine facility
Rental Flat
Hostel for workers
Drug addicts hideout Murder
Paranormal activity
Articles
Forums
Websites
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The Philosophy Building Brain, Brawn, Bones & Bonds
Share a pot is a community-based project to improve the nutrition and fitness of community-dwelling seniors.
Community Programs
(Strengthening & Coordination)
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A community that supports healthier living Wellness Kampung is an initiative comprising a network of three wellness and care centres for residents in the north. Our Wellness Kampung provides a suite of health and social programmes, creating a support network for residents to inspire each other to adopt healthier lifestyles, in a close-knit 'kampung' setting. WHC will be setting up similar facilities for communities in Woodlands Source: ktph.com.sg/wellness-kampung
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Chope by Christchurch Sec
Chope by Faith-based Organisations
EMPATHY
Chope by Woodgrove Sec
INTER-GEN
Chope by Evergreen Sec
“NUKA”
SOCIAL SUPERMARTKET
Creating and building a Community of Hope in the North
Chope by Corporates (Launching in Sep)
Desired outcomes for CHOPE X Schools Influencing behaviour changes in self | Influencing behavioural changes in the family | Increasing volunteerism in community | Public service as choice of career
CHOPE - Partnership - Volunteers
- Funding (Strengthening)
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Woodlands
Secondary School
Share A Pot Launched 5 Apr at
Marsiling Zone 3 RC
SELF-SUPPORTED COMMUNITIES
Canberra
Secondary School
Share A Pot Launched 25 Jun at
Sunlove SAC
(764B Golden Saffron)
Enhanced Share a Pot (WIP) • Hydroponics systems for schools –
sponsored by corporate donors • Farm to table
CHOPE - Partnership - Volunteers
- Funding (Strengthening)
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Postcard with profile of local Community Nurse and services
Pocket-size localised resource guide for Community Nurses
Community strategy| building strong communities
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NHGP
WHC
AdMC
Woodlands Planning Area
Community strategy| building strong communities
Building new CNPs, Share a Pot and Wellness Kampung sites by 2020
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Community Analysis (Sensing)
Nurses work SMART (Clinical/Care & Coordination)
CHOPE - Partnership - Volunteers
- Funding (Strengthening)
Community Programs
(Strengthening & Coordination)
Community Screenings
Business Analytics
Mapping & Outreach
Community Nursing & Nurse Post
Hospital to Home
(AIP-CCT)
CNS, SGO, CFC
GP & Home Health
Support
Schools
Businesses
Wellness Kampungs
Share a Pot/ Our Kitchen
Community Health &
Social Partners
Community Gym
Tact
ics
Engage to Understand
Engage for Partnership
(Funding & Volunteers)
Engage for TOMA (Top of mind awareness)
Engage for Collaboration
Stra
tegy
Sense needs &
capabilities
Strengthen capabilities of the
community
Providing accessible
Clinical/Care touch points
Coordinate seamless care navigation &
resources
Activities
Go
al
To create self-supported eco-systems, to empower our community to manage their health and age in place - building a resilient population and a thriving community.
Overview of Strategy
Religious Org
Tele-health support
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Known to Hospital (Hospital Registry)
Known to Community
Nurses (CN
Registry)
Pre-Hospital Tele-triage • GP / OPS / UCC / ED • Activation of CN based
on criteria
Discharge Support • Discharge planning ‘Triage
Office’ support • Discharge calls (introduce
community programmes) • Tele-follow up (AIP-CCT) • Vital signs monitoring
In-hospital Support • Push data from CN Registry to Hospital
System/CRM upon contact with hospital services • Trigger admission alert to relevant CN team
Unknown
Regional Population Registry Contact Centre Support Business as Usual • Appointments • Enquiries
Our work in the community
Linking back to our hospital
Community Analysis (Sensing)
Nurses work SMART (Clinical/Care & Coordination)
CHOPE - Partnership - Volunteers
- Funding (Strengthening)
Community Programs
(Strengthening & Coordination)
Community Screenings
Business Analytics
Mapping & Outreach
Community Nursing & Nurse Post
Hospital to Home
(AIP-CCT)
CNS, SGO, CFC
GP & Home Health
Support
Schools
Businesses
Wellness Kampungs
Share a Pot/ Our Kitchen
Community Health &
Social Partners
Community Gym
Religious Org
Tele-health support
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To reach out to various community assets and create common goals to work together
(Local religious institutions, business retailers, GPs, ILTC providers, VWOs, schools etc)
To understand the community
(Work closely with HDB, town councils, grassroots, SGO and thorugh door-to-door outreach)
To enable the community to be self-sufficient
(Co-creation/adoption of programmes with local champions, businesses, schools and
corporate sponsors)
We may have found the methodology of 2S2C
But the work is continuous..
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Thank You