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Winning neighbours

Changi General Hospital’s innovative and integrated health and social model clinches the National Clinical Excellence Team Award 2024 for its instrumental role in providing holistic care for seniors in the community.

By Ms Bavisha Assodani, CGH



The Neighbours team with Mr Ong Ye Kung, Minister for Health, at the National Medical Excellence Awards ceremony.

The team behind the Neighbours for Active Living Programme (Neighbours) — pioneered by Changi General Hospital (CGH) in partnership with the South East Community Development Council (SECDC) — was honoured for their dedication and innovation in transforming healthcare delivery. The initiative integrates health and social care, empowers communities, and significantly improves the quality of life for seniors in the community in eastern Singapore.

This marks the fourth consecutive win for CGH at the National Medical Excellence Awards, underscoring the role of the Caring General Hospital as the trusted care partner and leader in community care.
 

A visionary approach to community care

Social isolation and loneliness are associated with higher risks for health problems. An early champion of preventive care with a strong foundation in healthcare delivery in the community, CGH had identified the need for continual care and support for an increasing number of seniors in the community who lack adequate support to care for themselves or live alone. This led to the setting up of the Neighbours programme in 2013.

"To ensure that seniors with complex health-social needs continue to receive timely care after their discharge from hospital, the CGH Neighbours Community Care team developed a holistic, person-centred approach, which we continue to champion today," says Shirlyn Su, Assistant Director, Department of Health and Social Integration, CGH.
 


The Neighbours For Active Living Team at CGH.

Building a strong network of care

The Neighbours Community Care Team consists of a dedicated team of 50 healthcare professionals with both health and social care expertise. Together, they have made over 100,000 care calls and home visits to assess medical conditions, develop care plans and provide continual support for seniors in addressing long-term social and healthcare needs. They also built a robust and extensive community network of care support with national agencies, health and social care providers, grassroots and faith-based organisations.

The programme leverages the close ties of volunteers and neighbours to provide companionship and social support to vulnerable seniors, especially those who lack adequate support or live alone.

"At the heart of Neighbours is the concept that 'close neighbours are better than distant relatives', which has driven the team to actively involve volunteers from the community together with SECDC in supporting seniors," says Cheryl Lau May Ling, Senior Manager, Department of Health and Social Integration, CGH. “Over 900 volunteers from all walks of life have been trained and matched with seniors.”
 

Delivering a decade of impact

Over the past decade, Neighbours has provided personalised care to more than 14,000 seniors in 18 communities in eastern Singapore — in collaboration with over 70 community partners — demonstrating the power of place-based care in improving health outcomes. This has helped to reduce hospital readmissions and improve the overall quality of life for many senior residents.

One resident who has benefited from this programme is Mdm Mahhizon, who was frequently admitted to hospital and had multiple chronic medical conditions. As she lives alone, she was introduced to Neighbours Friend-A-Senior volunteers by the Neighbours Community Care Team, so that they could check in on her regularly, remind her about her medications and medical appointments, as well as provide emotional support and companionship.

“She is an angel that gives me encouragement and motivation when I am at my worst. I am very thankful for her in helping me stay well,” said Mdm Mahhizon about Mdm Salmiah, who is a Neighbours Friend-A-Senior volunteer.


Mdm Mahhizon, with her caregiver Mdm Zaiton and Neighbours Friend-A-Senior volunteer Mdm Salmiah.

"The Neighbours team forms the bridge between acute care and the community," adds Dr Low Shou Lin, Senior Consultant, Department of Geriatric Medicine, CGH. "They serve as our eyes and ears on the ground, and assist in following through care plans by alerting our medical team when volunteers notice any areas of concern that need attention."

To better assist residents with health and social needs, Neighbours collaborated with SingHealth Polyclinics to pilot the Primary Care-Based Integrated Care Team (PACE-IT) at Marine Parade Polyclinic, providing tailored health and social support for residents. Additionally, Neighbours partnered with two Active Ageing Centres to launch Assisted-Living pilot projects, enabling seniors to continue ageing-in-place with support. 
 

Redefining care for the population

With the introduction of Healthier SG in 2023, Neighbours has transitioned to a data-driven, place-based, population health approach, with its community care team members taking on the anchor role of Wellbeing Coordinators (WBCs) to manage the care of the population in the eastern community.

"It is heartening to know that the programme has created a lasting positive impact on the lives of seniors, and we will continue to focus on empowering them to get well and age well within their communities," says Ms Su, who led the programme together with Cheryl Lau May Ling, Senior Manager, Department of Health and Social Integration, CGH; Dr Low Shou Lin, Senior Consultant, Department of Geriatric Medicine, CGH; and Roy Chew Pei Wei, General Manager, SECDC.