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Community Nursing

With the introduction of community nursing programmes, our seniors can receive seamless and coordinated care in our community.

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Not “What’s the matter with you?” but “What matters to you?”​

Building a self-supported community starts from asking the people we serve, the right questions – the most important being “What matters to You?”

​This paradigm shift has helped us find better solutions to the challenges faced in caring for our community. Engaging partners and seniors in door-to-door outreach help us to understand needs of seniors living in our communit​y.

Since 2016, the community team and volunteers have together covered over 4,000 households through our outreach in the North. These insights are used for regular reviews of existing community programmes as well as the development of new initiatives that will bring better coordination of care for you and your loved ones.

With the introduction of community nursing programmes, our seniors can receive seamless and coordinated care in our community. ​​
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Community Nursing

To better serve an ageing population our Community Nurses, located across neighbourhoods in Yishun, Sembawang and Woodlands, form the heart and hands of our community care model.

Together with partners like General Practitioners, Polyclinics, Senior Activity Centres and home care providers, our Community Nurses are able to coordinate and provide care services ranging from disease prevention to chronic disease management and end-of-life care.

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SMART
Services provided by nurses under SMART (Self-Managed Autonomous Regional Teams)
  • Proactive home visits to residents referred by community partners
  • Chronic disease management and health coaching
  • Helping residents connect and navigate community care services
  • Teaching and empowering residents and families to manage their health more effectively through self-care

Referral Criteria:
  1. Resident lives in the North catchment area (i.e. Yishun, Mandai, Sembawang, Marsiling, Woodlands, Simpang)
  2. Resident has at least two of the following issues:
    1. Medical
      • Sub-optimal chronic disease control
    2. Nursing 
      • Difficulty in managing medications
      • Inadequate support for healthy lifestyle 
    3. Functional
      • Vulnerable / Mild Frailty (Clinical Frailty Scale 4-5)
      • History of multiple or near falls in the past six months
    4. Social 
      • Social isolation
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