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Community Nursing

Community Nursing provides an array of programmes and services to meet the diverse health-related needs of patients within the community. The scope and complexity of individual care needs vary amongst different community care settings. Community nurses work closely with our community partners to deliver patient-centred care beyond the hospital to the community. To ensure residents stay well, get well, and age well at home, CGH adopted the Communities of Care Model to meet the needs of the population in the East.

The services provided by the CGH Community Nursing team are:

Preventive Health Care

Community Nursing conducts screenings, assessments and interventions to support community preventive health programmes (e.g. Community Falls Prevention Programme). These programmes are collaboratively developed by Community Nursing alongside other healthcare and community partners, to screen seniors who are at risk for falls and to provide education on falls prevention. Those at risk will be referred to the appropriate health and community services to address their risk factors.

Community Nurse Post Service (CNP)

Community Nurse Posts (CNP) are a nurse-led service situated at the Senior Activities Centres, which is located at an accessible social care space. This service was developed based on the concept of asset-based community development, which aims to holistically address the determinants of health and needs of seniors within the community, in collaboration with social and community care partners, to support seniors ageing in place.

The service caters to the health needs of seniors in the community, focusing on empowering seniors to manage and improve their health. The scope of this service includes health and geriatric assessment, health coaching for disease prevention, chronic disease monitoring and self-management education, medication self-management support and education, as well as care referral and coordination. Telehealth service is also available where remote monitoring of resident’s vital signs and consultation can be done, leveraging technology and innovation. Click here for the list of CNP locations.

Home Based Care

The Hospital to Home Programme (H2H) is a home-based programme that supports patients who are frail with complex post-discharge care needs. The community nurses, alongside a multi-disciplinary team, provides interim care and support to the patients and their caregivers, to ensure a seamless transition of care from hospital to community.

Community nurses provide the following scopes of service at home to reduce the risk of readmission:

  • Nursing care and procedures
  • Specialised care management (e.g. Geriatric assessment and intervention)
  • Care coordination and case management
  • Patient and caregiver education and training

Community Psychogeriatric Programme

The Community Psychogeriatric Programme (CPGP) is a multi-disciplinary team that manages older persons with mental disorders in the Eastern community. For more information on CPGP, please click on this link

Enhancing Advance Care Planning, Geriatric Care and End of Life Care in the East (EAGLEcare Programme)

The EAGLEcare Programme empowers Nursing Home (NH) partners in the East to provide Advance Care Planning (ACP) services and deliver quality Geriatric and End-of-Life (EOL) care to eligible NH residents. Through a capability building and shared care model, the EAGLEcare Programme enables eligible NH residents to be cared for comfortably in the NH in the event of deterioration, according to their care preferences, with the support of CGH doctors and nurses.