Living with Frailty
A group exercise session organised by the CARITAS team

One of the challenges of an ageing population is the concomitant rise in ageing-related conditions. There are about 500,000 people in Singapore who are aged 65 years old and above. Of these, about 10% are frail and suffering from multiple problems, such as falls, arthritis, dementia, immobility, incontinence, chronic diseases (diabetes, hyperlipidaemia and hypertension), and social isolation.

Yishun Health aims to keep older adults who are affected by these issues healthy and robust for as long as possible — and to do this in the community that they are familiar with. This stems from our firm belief in person-centred care that must go beyond the biomedical to include psychological and social aspects.

In tailoring care plans for patients, we consider their personal history, values and preferences to ensure that the person is always at the centre of care and that, over and above medical needs, we tend to the key tenets of their quality of life.


Patients with dementia can be challenging to manage, especially in the home. Often, patients and caregivers require long-term support and help. To improve the care for frail older persons with dementia and support ageing in place, Yishun Health rolled out the CARITAS iCommunity @ North in 2012. The goals of care in this integrated care model are spelled out in its name:








CARITAS extends hospital dementia care into the community through links with day-care centres and home care providers (case management, counselling, caregiver support and training, home help, home medical and nursing care) and primary care providers.

Specialising in dementia, a transdisciplinary team of doctors, nurses, physiotherapists, occupational therapists, speech therapists, medical social workers, psychologists and pharmacists works with these community partners. Patients and their caregivers have ready access through a phone call or email to a patient care manager as their main point of contact. This heightens the responsiveness to ad hoc as well as long-term needs.

The team and their community partners meet weekly to discuss care plans, update each other on the status of patients, and share recommendations so that team members can act on each other’s inputs to offer timely and proactive care. Today, CARITAS — together with partners such as St Luke’s Eldercare, SWAMI Home, Sree Narayana Mission, AWWA, Thye Hua Kwan Moral Society, Montfort Care, NTUC Eldercare, Club Heal, Agency for Integrated Care, Community Networks for Seniors, and Yishun Health’s Ageing-in-Place Community Care Team — serves more than 800 patients with dementia with differing levels of frailty and co-morbidities in the North.

In every CARITAS team, a patient care manager acts as the main point of contact for the patient and his family. This ensures care continuity and reassures caregivers that help is just a phone call or SMS away. He or she fosters an enduring relationship with the patient and family, and ensures that the different parts of the team are all kept abreast of important issues.

Members of the CARITAS team having a discussion


Community Care Partners, such as day centres, home care services, and eldercare services, play a central role in providing day-to-day care and services. They act as main points of care on the ground, ensuring reliable and accessible care. In turn, they are supported by Yishun Health’s transdisciplinary geriatric care team.

Physicians ensure that patients have an individualised care plan, and that clinical issues are adequately managed. More importantly, they motivate and ensure team members take to heart the CARITAS principles in care delivery.

Nurses and Occupational Therapists work together with caregivers to plan appropriate activities or interventions to improve the well-being, function and mobility of the patients with dementia. They also match interventions appropriate to the needs and capabilities of the patient to help upkeep a good quality of life.

Pharmacists educate patients and their family members on the purpose of medications and their possible side effects. They also check on medication compliance and explain its importance.

Medical Social Workers make sure that the patient and family receive support, be it in the form of funding, grants or access to services. They also make sure that caregivers receive adequate help and assistance such as training or respite care.

CARITAS Nurses with CCT and SMART Nurses conduct regular home visits to provide medical and nursing care. During these visits, they tend to all needs, be they medical or social. They also look out for the well-being of the caregivers.


Dementia poses many challenges. It has a significant impact on healthcare costs, increases caregiver stress, and reduces the quality of life not only for those with dementia, but their families as well. The disease is often complex and co-exists with other chronic illnesses. This underscores the need for a care model that is both holistic and individualised.

CARITAS is an example of a complex-adaptive system (CAS) that factors the potential changes and fluctuations into the patient’s condition. Instead of a rigid system based on predictable outcomes, CAS is open to dynamic circumstances. As it is made up of interdependent and semi-autonomous team members (doctors, nurses, care providers, etc.), it is self-organising. Each team member is able to adapt to less predictable and unplanned situations, which is pivotal to keeping pace with patients’ and caregivers’ changing needs.

Care is delivered primarily through a patient care manager drawing on the team’s resources, affording the team consistent two-way communication to discuss about the patients. Telemedicine is also utilised to provide decision support for primary and community care providers. Besides service providers, family members of persons with dementia (PWD) are actively engaged and empowered in the development of care plans and delivery of care for the PWD.


The impact of CARITAS was evaluated in a pilot study on 97 patients. After three to six months under the programme, patients and their families reported improvements:

There was a significant reduction in patients’ behavioural problems and caregiver burden

There was an improvement in overall quality of life across all dementia severities. Importantly, those with higher dementia severity saw more marked improvements

The programme was also found to be cost-effective

The team presented these findings at the Global Conference on Integrated Care in 2018 and was named Best Oral Presentation.

To further improve dementia diagnosis and referral in primary and community care, a web-based app was also developed. This innovation clinched first prize in the ‘Better’ category of the Yishun Health Kaizen Competition 2017, and was featured at the Future Med Conference 2017.


Care for the Acute Mentally Infirm Elder (CAMIE) is a restraint-free care ward started in 2012. Since then, the ward has provided evidence that a restraint-free setting leads to better clinical outcomes and is also cost-effective.

Forget Us Not is a dementia-friendly community initiative in partnership with the Lien Foundation and Alzheimer’s Disease Association. Since it started, it has trained more than 20,000 lay people from more than 90 organisations to recognise the signs of dementia, learn tips to stave off dementia, and provide assistance to people with dementia who need help.

Self-Administration Of Medication (SAM) is an initiative that empowers patients to manage and consume their own medication correctly and safely, even after being discharged from hospital.

Ageing-in-Place Community Care Team (AIP-CCT) is a post-discharge, nurse-led home visit service that ensures comprehensive clinical, psychosocial and home environmental support and care for patients at home.

An AIP-CCT nurse visiting one of her charges at home

The programmes that this service rolled out in FY2017 include:

The transition of the Frequent Admitter Programme and Transitional Care Programme to the Home to Hospital (H2H) programme, which is administered by the Agency for Integrated Care (AIC)

Preventing Re-Admissions though Telephone-Based Consultation

Home Visit Volunteer Programme

Ageing-in-Place System (AIP System) for taking case notes on the go

The ‘Keep Cool’ Project to keep blood samples cool when drawn from patients in their homes

Collaborations the Home Nursing Foundation, nursing homes, Wellness Kampungs and AdMC’s Diabetes Centre