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To add to Bee Yee's suggestion, collaborations with community partners could also move beyond rehab to include speech therapy, dietetic services etc.

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To add to Bee Yee's suggestion, collaborations with community partners could also move beyond rehab to include speech therapy, dietetic services etc.

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To be a thought leader and forerunner in ILTC care standards and medical capabilities. SCH will be an ideal partner to collaborate with IHLs, A*STAR and Med tech companies to test-bed new technologies and devices for patient rehab and home care.

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Follow the mind space and "daily activities of living" of the layperson. Telcos, coffee shops, etc are natural catchment areas that are useful to gain change in social behaviours with an overall health objective. These would be for more upstream and preventative measures

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Vision, hearing and oral health screening

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Consider change of operating hours of DRC 

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Consider change of operating hours of DRC 

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Standardization of tele rehab, and training of using tele rehab starts from CH 

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Standardization of tele rehab, and training of using tele rehab starts from CH 

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Partnership in education and awareness of community rehab providers so that there is positive association with rehab provided by public hospital clusters. Sometimes the community have the perception that hospital rehab is better. We have to help our partners gain credence amongst the public, esp in newer towns.

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To expand on the community services and their accessibility 

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To expand on the community services and their accessibility 

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Better support for dementia patients who also have rehab care needs.

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One way is to have a joint office manned by both AIC and SCH staff to better coordinate discharge and transition of care to community partners.

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Engage volunteers to assist with telerehab 

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Engage volunteers to assist with telerehab 

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Needs to understand needs of the population of our community partners are serving (geriatrics pop Vs working adults/adolescence)

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Needs to understand needs of the population of our community partners are serving (geriatrics pop Vs working adults/adolescence)

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Establish a package deal (include DRC service cost) 

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Establish a package deal (include DRC service cost) 

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Rehab on community integration can be improved so that patients can get out of their homes with confidence.

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Community Dietetics and Nutrition Workgroup (COMDAN) looking at establishing national model for community dietetics e.g. GPs referrals to dietitians, training comm partners to provide general diet advice

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Collaborate with other service providers e.g. SHP to offer 1-stop spectrum of rehab from MSK to geri/neuro etc.

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IPCar can use the existing Community Nursing program currently run by RHS - where nurses visit patients in their homes to ensure they remain well.
This will not only add value but also form a niche to Comm Nursing.

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To work on subsidy subvention and accessibility of medications 

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To work on subsidy subvention and accessibility of medications 

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Extension of Medication therapy management (MTM) by SCH pharmacists beyond discharge

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Partner with AIC to provide support or continue CGT post discharge 

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Partner with AIC to provide support or continue CGT post discharge 

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Understand reasons of patients for not continuing with comm rehab after discharge e.g. last-mile access from home to/fro transport pick-up and drop-off

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Walk in rehab clinics that need not be through referral from hospitals

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Walk in rehab clinics that need not be through referral from hospitals

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Perhaps SCH could consider providing continuing education services to community partners in the areas of community care.

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Perhaps SCH could consider providing continuing education services to community partners in the areas of community care.

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Work on VDC conditions eg capture the fracture initiative for osteoporosis, Halt CKD for patients with hypertension and CRF 

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Work on VDC conditions eg capture the fracture initiative for osteoporosis, Halt CKD for patients with hypertension and CRF 

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Fold comm nursing with GP empanelment. Both patients and GPs benefit from a larger network of nurses/case managers as the conduit between hospital and community.

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Build in infrastructure for seamless referral & follow up 

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Build in infrastructure for seamless referral & follow up 

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Have we ocnsidered healthcare befriender - a concept much like social befriender

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SCH could manage the cases in terms of the patient journey in the community. This will provide greater assurance and confidence to patients, and also alleviate the management load on Community partners as they are usually not as well resourced.

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SCH could manage the cases in terms of the patient journey in the community. This will provide greater assurance and confidence to patients, and also alleviate the management load on Community partners as they are usually not as well resourced.

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Community Nursing and community pharmacy involvement should be considered. Majority of patient cares can be supported by them 

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Community Nursing and community pharmacy involvement should be considered. Majority of patient cares can be supported by them 

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To work with community partners on what are available in the community beside DRC 

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To work with community partners on what are available in the community beside DRC 

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Patient education is important as they may not see the need to receive care after their discharge 

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Patient education is important as they may not see the need to receive care after their discharge 

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Combination of MDT to participate in pt care such as finance, rehab, nurse, dr etc.

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Combination of MDT to participate in pt care such as finance, rehab, nurse, dr etc.

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Establish structured partnership where there is communication & feedback flow (referral, care plan, follow up & evaluation)

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Establish structured partnership where there is communication & feedback flow (referral, care plan, follow up & evaluation)

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Home nursing association can be used for home visits.

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Work on developing pathway/protocol for secondary and tertiary prevention for VDC conditions .. let primary care physicians focus on primary prevention for DM/hypt/hyperlipidemia 

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Work on developing pathway/protocol for secondary and tertiary prevention for VDC conditions .. let primary care physicians focus on primary prevention for DM/hypt/hyperlipidemia 

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Allow GP partners admitting rights to community hospitals (in consultation with community hospital doctors). This will engender GPs as a stronger partner and with skin in the game.

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To understand the needs and barriers of the care transition and hospital @home so that we can better partnership 

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To understand the needs and barriers of the care transition and hospital @home so that we can better partnership 

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Continue nursing care support when patient discharge (complex case).