THE INTEGRATED CARE MODEL
Yishun Health works on the integrated care model of healthcare, which straddles the spectrum from the acute hospital and the community hospital to empowering the community to stay healthy.
Central to this idea of integrated care is removing silos and ensuring that doctors have the right capabilities and aptitudes to cross the traditional boundaries of care.
This approach moves away from episodic ad hoc care, enhances the communication and collaboration between every medical professional, and builds a greater sense of ownership of every patient. Regardless of where the patient is sited within the campus, our doctors readily cross boundaries to treat them. This results in seamless, timely and integrated right-sited care.
KNOWING OUR COMMUNITY
One way we strategically and efficiently deliver care is to take into consideration the unique needs of our patients and community understanding their profiles, their needs, and the levels of care they require.
This knowledge not only helps us better serve and design care, but puts patients at the centre of all our plans and strategies.
KNOWING OUR PATIENTS
Critical to our unified person-centric clinical care model is a deep understanding of the community we serve. This enables us to develop the right services and deliver these at the right time and stage of health.
Living with Illness: This focuses on transforming primary care and building up the NHG Primary Care Network and developing an empanelment model within the next two years. We aim to achieve a care model for GPs that will mirror team-based care, or through teams at NHGP.
Crisis and Complex Care: As we transform the way our hospitals deliver and integrat e care for patients, our focus is centred around building relationships, understand ing patient’s needs to minimise admissions, reducing bed crunch issues, and enabling continuous patient care.
Living with Frailty: We focus on enabling care transitions that encompass prevention and early detection of frailty, safe hospital care, and seamless integration that empowers the identified pre-frail and frail populations to stay well in the community, with resultant impact of reduction in ad hoc crises, especially with frail elderly.
Leaving Well: We take a holistic approach to support end-of-life patients and enable them to make the choices that they desire, with home support and alternative plans for those without home support. Advanced Care Planning (ACP) is facilitated by healthcare professionals who have trusted relationships with appropriately stratified patients. ACP should be undertaken proactively and not be done only when a crisis or immediate need arises.
Time should be allowed for patients to think through, make decisions, and document their care plans and preferred choices.