General practitioners (GPs) often see patients whose recovery is hindered by social or personal circumstances. With the Neighbours programme, support is now available for GPs beyond the clinical setting to support patients in managing their health and well-being.
The Neighbours for Active Living (Neighbours) programme aims to ensure that patients with complex health and social care needs continue to receive care in the community, after their discharge from the hospital.
Set up in 2013 by Changi General Hospital (CGH), the Neighbours team now consists of 50 community care professionals with social work and nursing backgrounds. Serving 18 communities in the East, it works closely with SingHealth Community Nurses as an integrated community care team to support the health and social care needs of residents referred by hospitals, general practitioners (GPs), polyclinics and social service agencies.
CASE A: MDM K
70-year-old Mdm K sees a GP for her chronic conditions such as diabetes and poorly controlled hypertension. She lives alone, only occasionally visited by a niece.
Her GP, who has known her for a long time, was concerned about her slowly deteriorating health status. She referred her to the Neighbours team to help check on her well-being and to see if she can be encouraged to take better care of herself.
During home visits, we found out that Mdm K had difficulty remembering her medication regimen, and did not measure her blood pressure (BP) regularly. We therefore created a visual aid to help remind and guide her to take her medication, and to measure her BP.
As Mdm K also had some visual challenges, we created a log sheet big enough for her to see and easily fill in after measuring her BP. The team spent a few days walking through the whole process with her till she was able to remember to measure her BP daily. We also reminded her to bring her BP log to her GP, whom she continues to see every three months, for review.
As a result, Mdm K was able to keep her hypertension under control.
CASE B: MDM D
50-year-old Mdm D sees her GP for hypertension and diabetes. She had been self-managing quite well on her own but recently came to her GP, distraught. Mdm D shared that she was going through a crisis with her daughter, who refusedto seek help for a suspected mental health condition which affected the latter’s behaviour severely.
After the clinic visit, her GP requested the Neighbours team to help assess what was happening at home.
The Neighbours team visited Mdm D and was able to have a conversation with her daughter, who eventually agreed to her family taking her to a mental health specialist. She was diagnosed with clinical depression and treated in time.
This put Mdm D’s mind at ease and she was able to refocus her energies on managing her own health conditions.
Consider making a referral to Neighbours if you have patients who:
For referrals and enquiries, please email to email@example.com.
A Neighbours staff member will respond to you and maintain communication via phone call or email. The patient’s progress will be fed back to the referring doctor when there are changes in his/her health and psychosocial status.
For more details on the Neighbours programme, please visit the website.
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