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Community care at CGH has also flourished. Through health screenings, coaching, home visits, wellness hubs and specialised programmes, we continue to branch out, meeting residents’ health needs at every stage of life.
Providing a firm foundation for this outreach are dedicated community partners comprising medical institutions, Active Ageing Centres, general practitioners (GPs), social service agencies, grassroots groups, volunteers and neighbours. They are the pulse of a thriving community care network that extends CGH’s services to more than 750,000 residents across Tampines, Bedok, Pasir Ris-Changi and Geylang East – enabling the Caring General Hospital to bring healing beyond our four walls.
MORE THAN CARE, THIS COMMUNITY NURSE SUPPORTS A BETTER QUALITY OF LIFE
Seah Yuh Tyng
Senior Staff Nurse, Department of Community Nursing
Good health is the most important thing in life, but to truly live requires independence. Community nurse Seah Yuh Tyng knows this well. In fact, she has dedicated her career to helping patients achieve it.
During regular home visits to patients in the community, Yuh Tyng conducts physical and mental check-ups and offers health advice for residents.
With over two decades of healthcare experience in the community, Yuh Tyng’s journey took a pivotal turn when she joined CGH’s transitional care team in 2013. Four years later, she became part of the pioneering team that established CGH Community Nursing in 2017, an initiative under the national nursing workforce transformation designed to deliver population-centric, geographically focused care. What began as a modest team of five nurses has flourished to a staff strength of 80 today.
Yuh Tyng balances her professional duties with her role as a caregiver at home. Rising at 6am daily to care for her father with dementia, she takes him safely to day care before beginning her work day. This personal experience helps her connect authentically with families navigating similar challenges.
Her day is split across two distinct yet interconnected spheres: overseeing Community Health Posts at Active Ageing Centres (AACs), where she monitors residents’ chronic conditions and overall wellbeing, and conducting Hospital to Home (H2H) visits. These home visits provide crucial post-discharge care and comprehensive support for patients with complex health and social needs, delivered through collaborative multidisciplinary teams.
Younger nurses in CGH also benefit from Yuh Tyng’s nurturing, as she provides support beyond clinical coaching, drawing upon lessons in adaptability, alertness and communication learned from her own mentors. As community nurses often work alone, they face unique challenges, including performing procedures single-handedly or navigating complex family dynamics. Her mentoring approach involves strategically pairing new nurses with more experienced colleagues across varied cases, ensuring comprehensive exposure to the field’s complexities. “I try to let them handle complex cases to see different situations, so they know how to make decisions about what cases need to be escalated more quickly,” shares Yuh Tyng.
Today, Yuh Tyng remains steadfast in her mission to provide a service that not only delivers exceptional home medical and nursing support, but one that fundamentally transforms lives.
Community nurses are among the dedicated frontliners instrumentalin CGH’s push to make healthcare accessible to patients in our community. They work primarily in the field, extending CGH’s reach deep into the community by personally delivering quality place-based care and support, particularly to residents with mobility issues and seniors who live alone.
To enable them to travel more efficiently and carry out their duties with ease, CGH community nurses worked with the Office of Innovation to co-design a mobile workstation for use on home visits.
Beyond home visits that give seniors the assurance to age gracefully, knowing they are supported by skilled professionals who understand their medical and social needs, community nurses also collaborate with primary and community care partners to deliver integrated, place-based care that empowers patients to achieve their health aspirations as part of the national Healthier SG strategy.
Partnerships are forged with Active Ageing Centres and diverse community stakeholders – including Community Clubs, Resident Networks and faith-based organisations – to establish Community Health Posts throughout neighbourhoods. These strategically positioned health touchpoints provide residents with convenient access to primary care, specialised geriatric services, comprehensive health assessments and chronic disease management support. This seamless care model enables residents to maintain optimal health whilst providing their caregivers with peace of mind, knowing that quality care for their ageing loved ones remains accessible close tohome.
Family Nexus@Our Tampines Hub, a one-stop family hub, aims to provide health, social and community services and programmes under one roof. With a focus on women’s and children’s health, the centre offers mothers post natal physical recovery and mental wellness screening, as well as breastfeeding and lactation support, while children aged six years old and below are offered growth, development and nutrition support, plus oral health screening and education.Services like these are an integral part of CGH’s outreach and have transformed community nursing into a robust branch of our comprehensive community care ecosystem.
GPFIRST: RIGHT CARE AT THE RIGHT PLACE
CGH’s GPFirst initiative, a recipient of the NMEA in 2021, enhances healthcare quality by reducing pressure on our Emergency Department (ED). By encouraging families to see their family physicians in the community for mild to moderate ailments, GPFirst also empowers GPs to manage a wider range of cases.
Between 2014 to 2019, CGH saw 36% fewer ED patients without a doctor’s referral, and 14% fewer non-urgent cases. This benefitted over 33,000 patients – a huge credit to the GPFirst team’s research and collaborative efforts.
The CGH GPFirst team aims to empower GPs and ease the pressures on hospitals’ emergency departments, fostering continuity of care for patients in the community.
Clin Assoc Prof How Choon How, Chairman, Division of Continuity Care and Director, SingHealth Office of Regional Health (East Campus), consults with GPs.
Uniting over 80% of GP clinics in the eastern region, GPFirst underscores CGH’s commitment to empowering GPs as the first point of contact for healthcare needs. This also aligns with the nation’s wider Healthier SG goal of fostering a stronger relationship between families and their family physicians, to maintain continuity of care and contribute to a more integrated healthcare ecosystem.
Commenting on this ecosystem that facilitates seamless care, Mas Riza Bte Mohd Razali, Senior Manager, CGH Regional Health System Division (RHS) (Community), explains the most crucial element of working in community care and driving such population health initiatives: establishing and building trustworthy relationships between CGH and its stakeholders, while also creating bridges and connections for our patients.
With the launch of Healthier SG in 2022, GPFirst was identified as a programme to be nationalised. As the forerunner of GPFirst, CGH took on a leadership role in scaling the programme nationwide through the GPFirst Extension Action Team(GPFEAT). Co-led by the Ministry of Health (MOH) and CGH, GPFEAT provided advisory support and guidance to other public hospitals as they implemented GPFirst, leveraging CGH’s pioneering experience and expertise in the programme.
For Mas, who is also a core team member of GPFEAT, the expansion of the programme exemplifies our push to branch out care to the community. “CGH is an integral part of the community’s healthcare and wellbeing ecosystem, working alongside community health partners and resources to provide improved care for our residents,” she affirms.
CARELINE: A 24/7 LIFELINE FOR VULNERABLE SENIORS
From empowering family doctors, CGH turned our attention to vulnerable seniors living alone. Singapore’s population of seniors aged 65 and above has surged from 338,000 in 2010 to 614,000 in 2020, and is projected to exceed 900,000 by 2030, giving rise to a super-aged society. In 2016, CGH launched CareLine to address this growing challenge.
Koh Siew Hoo, a CareLine Care Operator, stays dedicated to the wellbeing of our seniors and remains available for callers who are in need of assistance.
This round-the-clock phone service connects seniors to more than 130 community partners, including the Silver Generation Office and social service agencies. With healthcare resources and a listening ear just a phone call away, seniors have the assurance to lead meaningful lives. The service’s multilingual capability further enhances its accessibility, offering support in English, Mandarin and Malay, as well as dialects including Hokkien, Teochew and Cantonese. CareLine was honoured with the NMEA in 2022 for its commitment to ensuring the wellbeing of vulnerable seniors, especially those living alone or with compromised health.
Building on CareLine’s success, the service was integrated with the Housing & Development Board’s (HDB) Project LIFE initiative in 2019. The integration of a wireless Alert Alarm System in seniors’ homes has further enhanced CareLine’s ability to provide preventive care, respond promptly to seniors in distress, and effectively reduce false alerts. The wireless system ensures seniors can communicate their needs, especially when urgent coordination is required, and even when they do not have access to a phone.
With plans to expand across all rental blocks nationwide under the Age Well initiatives by 2025, CareLine continues to grow its reach and impact, having revolutionised telecare in Singapore and benefitted more than 24,000 seniors to date.
The CareLine team received the NMEA - National Clinical Excellence Team Award in 2022.
EAGLECARE: SOARING TO EXCELLENCE IN END-OF-LIFE CARE
The programme known as ‘Enhancing Advance Care Planning, Geriatric Care and End of Life Care in Nursing Homes in the East’, or EAGLEcare, was distinguished with the NMEA in 2023 for its holistic approach to nursing home care.
A collaboration between CGH and community partner St. Andrew’s Community Hospital (SACH), EAGLEcare combines expertise in geriatric and palliative care with family insights to provide comfort for nursing home residents in their final stages of life, whilst ensuring access to clinical care around the clock.
Ng Foong Ling, Assistant Director of Intermediate and Long-Term Care (ILTC) Integration at CGH plays a key role behind the scenes, ensuring clear and timely communication across hospital teams, community care partners, nursing home residents and their caregivers. For her, this coordination is integral to delivering quality patient-centred care.
The EAGLEcare clinical team conducts hands-on training sessions in palliative and end-of-life care for nursing home staff.
Indeed, the team keeps an eagle eye on improving the lives of residents. For example, the EAGLEcare team collaborates with SACH to provide after-hours symptom management at nursing homes. Many end of-life residents experience uncontrollable symptoms, often after working hours, and have to be admitted to hospital. The initiative alleviates the stress on residents, caregivers and staff caused by these unplanned hospital admissions.
The programme’s impact has been remarkable. From 2019 to 2023, EAGLEcare has significantly reduced emergency department visits, hospital admissions, and hospital lengths of stay among enrolled residents by over 33% in their last month of life, while honouring over 99% of enrolled residents’ treatment preferences and 91% of their preferred place of death. More than 1,460 nursing home staff have also been equipped with advance care planning and palliative care skills, creating lasting capability within the community.
The EAGLEcare team received the NMEA - National Clinical Excellence Team Award in 2023.
NEIGHBOURS: A CLOSE-KNIT COMMUNITY REACHES OUT
In 2013, CGH and the South East Community Development Council (SECDC) began cultivating social networks within neighbourhoods to make support available to the increasing number of seniors with inadequate resources to care for themselves, especially those facing social isolation.
From this vision of activating communities through an integrated health and social model sprouted the Neighbours for Active Living Programme (Neighbours). It ensures seniors receive timely care after hospital discharge whilst building supportive relationships within their communities – empowering seniors to proactively manage their wellbeing, foster resilience, and age healthily within their communities.
Neighbours’ success stems from its dedicated team of 50 healthcare professionals combining health and social care expertise. Their work is supplemented by the social support of more than 200 volunteers from national agencies, health and social care providers, and grassroots and faith-based organisations – neighbours who share meaningful friendships with the seniors.
The Neighbours care team conducts home visits to provide holistic assessments of patients’ health and social care needs, and where necessary, facilitates care escalation to the hospital.
The Neighbours team received the National Clinical Excellence Team Award in 2024, marking CGH’s fourth consecutive win at the NMEA.
The team conducts holistic assessmentsof patients’ health and social care needs, identifies and coordinates services for those with complex medical and social requirements, and provides regular home visits to assess patients’ conditions and safety. By 2025, they have made over 150,000 care calls and home visits, touching the lives of more than 17,000 residents.
In 2024, Neighbours received an NMEA in recognition of a decade of contributions that have successfully prevented countless hospital readmissions, and for the team’s efforts that cultivated meaningful relationships that enrich patients’ lives in the community. Embodying the Chinese adage ‘Close neighbours are better than distant relatives’, Neighbours demonstrates how community connections can transform healthcare delivery and create lasting positive change for vulnerable seniors.
For many older adults, mental health challenges such as anxiety, depression or dementia can sometimes be as debilitating as physical ailments. For seniors who are not able to come to the hospital, a team of psychiatrists, psychologists, community nurses, medical social workers, occupational therapists, physiotherapists and other support staff assesses conditions and delivers personalised mental health care and social support at home under our Community Psychogeriatric Programme (CPGP).
Established in 2007, CPGP offers home-based mental health care for seniors aged 65 and above who do not have easy access hospital or outpatient services. Our goal is to guide patients to better wellbeing by creating a nourishing environment that fosters independence and quality of life.
At home, the CPGP team equips caregivers with skills and knowledge in medication use and behavioural strategies to better manage mental health conditions, easing the strain of daily responsibilities and reducing the need for stressful hospital trips.
Better wellbeing is a process. In CPGP, this is well supported by strong community partnerships. GPs are instrumental in early detection and intervention, as they would be among the first to identify early signs of mental health issues. The team also connects patients to financial assistance if they need it, or to elderly and social service agencies that can take care of their everyday needs. With CPGP training and education, these agencies support mental health screenings and mental health management, fortifying the programme’s holistic care model.
As part of the CPGP, CGH trains social service and eldercare agency partners on areas to look out for when interacting with patients in the community.
CGH’s efforts to boost mental health are also focused on the developing minds of youth. Although the two groups may share similar vulnerabilities to stress, anxiety and depression, the factors and challenges are very different, hence the approach differs too.
Complementing CPGP is the Youth Outreach Programme (YoOp!), launched in 2021 to reach out to schools in the region to address the multi-faceted issues faced by youths. School pressures may be non-academic, caused by issues with relationships, on social media or even at home. A 2024 study on youths aged 15 to 35 by the Institute of Mental Health found symptoms of anxiety in 27% of the group, depression in 15% and stress in 13%.
YoOp! builds awareness and dispels myths about mental illness, empowering teachers and students to identify mental health issues. Through training, teachers and counsellors are equipped with the tools and communication skills to reach out to at-risk students. By changing mindsets and establishing support all around, YoOp! aims to create a psychologically safe ecosystem for students to thrive.
As Singapore’s healthcare landscape bends and shifts, innovative services like home-based hospital care and telecare are quietly transforming how patients experience treatment. Apart from improving the quality of care for those in the community, these new models of care reimagine the delivery of care itself, weaving support into the fabric of patients’ daily lives. Through these emerging models of care, CGH is crafting a more accessible healthcare ecosystem that flows seamlessly into the community’s rhythm and responds to its evolving needs.
One example is CGH@Home, which represents a significant step forward in providing patient-centred care beyond the hospital, while optimising hospital resources. As our adaptation of the nationwide Mobile Inpatient Care-at-Home (MIC@Home) programme, CGH@Home enables patients with acute conditions, many of whom come in through the Emergency Department and may require admission, to receive hospital-level treatment in the comfort and convenience of their own homes. While ‘warded’ at home, patients are provided with comprehensive and well-coordinated care including 24/7 monitoring, daily virtual consultations with doctors, and home visits by nurses and other healthcare professionals as needed. Designed for patients who are clinically stable, this programme ensures that patients receive the same level of attention and expertise they would expect in a hospital setting, but with the added benefits of personalised care, reduced stress, and a more relaxed and familiar environment for recovery.
A CGH Wellbeing Coordinator and volunteers conduct a home visit to check in on senior patients as part of the Neighbours programme.
CGH senior leadership and Mr Mohd Fahmi Aliman, then-Mayor of South East District attend the 2025 Neighbours Volunteers’ Appreciation Day, where an expanded volunteer befriending programme known as ‘Circle of Care @ South East’ was unveiled to drive health literacy and help more residents to get well, keep well, and age well within the community.
Complementing CGH@Home is the Hospital-to-Home (H2H) programme, which focuses on providing seamless transitional care for patients following their discharge from hospital. The H2H team works closely with patients and their caregivers to develop individualised care plans, offering education, support and resources to help them manage their health effectively at home. The programme includes home visits, medication reviews and referrals to community-based services, ensuring that patients have the tools and knowledge they need to stay healthy. Together with the Community Health Posts at Active Ageing Centres and other neighbourhood health and social care providers, H2H supports patients in the community and reduces the risk of hospital readmission.
In addition to home-based hospital care, we leverage telehealth to expand our reach and improve access to care for a wider range of patients. Through various telecare programmes, CGH provides remote monitoring, education, medical consultation and social support to empower patients to better manage their health from home. Telehealth also enables CGH to conduct physiotherapy, occupational and speech therapy sessions remotely.
These telehealth initiatives address challenges like geographic barriers and mobility limitations, enabling patients in remote areas or those with difficulty travelling to access specialist care and support. This was particularly significant during the COVID-19 pandemic, when telehealth enabled care continuity through safe-distancing measures, ensuring that residents had access to healthcare.
Under the CGH@Home care model, our multidisciplinary care team manages a multitude of medical conditions, offering patients hospital-type care in the comfort of their home.
New models of care bring exciting possibilities for healthcare. CGH’s commitment to embracing innovations is transforming healthcare delivery and improving the lives of patients throughout the community. By delivering the best of traditional hospital care through home-based and telecare services, we are creating a more accessible, convenient and patient-centred healthcare system for all.
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