Stories that define us
Support for Singaporeans as their “tree rings” increase
As trees age, their roots spread wider for greater support. Similarly, SingHealth has been growing its foundation of care for Singapore’s ageing population and those with chronic diseases. We are here to help realise Singapore’s vision of aging well and in place, supported by our network of healthcare providers and community partners.
Our tree of support first took root in 2011 with the ECHO programme, and many care initiatives have blossomed since. We are proud to share the milestones that have marked our population-health journey, with two significant achievements below:
- The Regional Health System (RHS), inaugurated in 2014, was part of a national drive to strengthen primary care through family doctors. These doctors who see individuals as whole persons, not just patients, recognising how social, lifestyle and environmental factors can impact their health.
- Singapore’s White Paper on Healthier SG in 2022 publicly shared the government’s commitment to population health. SingHealth has been tasked to oversee this mandate for Eastern Singapore.
Join us in exploring the milestones and programmes that SingHealth developed to support our nation’s vision!
2011
Eastern Community Health Outreach
(ECHO) programme launched
The Eastern Health Alliance first introduced
the ECHO programme in Changi-Simei - a
caring initiative that brought health
screening and personal health coaching right
to our community’s doorstep. Building on its
success, we expanded the programme in 2012
to reach residents in Tampines and
eventually all 17 constituencies in the
East.
2013
Introduction of Community
Coordinators/Community Assistants (2023:
Redesignated as Wellbeing Coordinators
[WBCs])
Our SingHealth WBCs are dedicated health and
social-care integrators who provide
holistic, person-centred care for residents.
Today, we have 100 WBCs working as part of
multi-disciplinary teams across diverse care
settings. Most of these caring professionals
serve in our SingHealth Healthier SG (HSG)
teams, where they connect with residents
through home visits and at Community Health
Posts (CHPs).
2014
Introduction of Patient Navigators
(PNs)
PNs provide vital support to residents,
especially seniors with complex health and
social needs, guiding them through the
healthcare system and ensuring smooth
transitions between different types of care.
Through their dedicated work, we see fewer
hospital readmissions, enabling more
residents to receive care comfortably in the
community while better managing their health
conditions.
SingHealth RHS Office established
Regional Health Systems are part of a
nationwide effort to drive population health
and deliver appropriate integrated care in
the right setting, at the right time. To
support this important work, the RHS Office
was established to coordinate and oversee
the various programmes under our care.
GPFirst programme established
GPFirst, an initiative by Changi General
Hospital (CGH), encourages residents in the
East to visit their trusted General
Practitioners (GPs) for mild to moderate
medical conditions, instead of going
straight to the emergency department.
2015
EAGLECare (Enhancing Advance Care
Planning, Geriatric Care and End of Life
Care in Nursing Homes in the East)
established
EAGLECare, established by CGH, partners with
nursing homes to provide compassionate
support in advance care planning, geriatric,
geriatric care and end-of-life care. Through
this programme, nursing home residents
receive personalised care that respects
their wishes and preferences, helping them
stay comfortable in familiar surroundings
and avoiding unnecessary hospital visits.
The team’s dedication was recognised with the National Clinical Excellence Team Award 2023. Their commitment to dignified care showed remarkable results from 2020 to 2022: they honoured 99% of enrolled residents’ treatment preferences and helped 91% of residents fulfil their wish to spend their final moments in their nursing home.
2016
ESTHER Network Singapore launched
ESTHER Network advocates a philosophy of
person-centred care, focusing on what
matters to residents with complex care
needs. Our goal is simple: to help residents
to live confidently and independently in the
community. Our ESTHER coaches - health and
social-care providers who work closely with
residents – ensure that the care provided
aligns meaningfully with the residents’ life
goals.
CareLine launched
CareLine, a personal care telephone service
pioneered by CGH, provides round-the-clock
health and social support to vulnerable
seniors who need urgent assistance. We are
proud that more than 20,000 seniors have
enrolled for the service. Working
hand-in-hand with 131 community partners
across Singapore, we help our seniors safe
and healthy in the comfort of their own
home.
2017
Official introduction of SingHealth
Community Nurses
Our Community Nurses bring care right to our
residents’ doorsteps through various
Ministry of Health (MOH) RHS programmes.
These include the Hospital-to-Home
Programme, which helps residents transition
smoothly back home after hospital stays, and
the MOH RHS-led Community Nursing Pilot.
First Community Nurse Post (CNP)
launched in the East (2023: Renamed
CHPs)
CHPs are touchpoints in the community for
residents to access healthcare services and
nursing consults. They are conveniently
located within Active Ageing Centres,
Community Clubs, Residents’ Network Centres
or other public spaces within the
neighbourhood.
SingHealth Partners Primary Care
Network (PCN) officially appointed
The PCN scheme brings private GP clinics
together to provide more comprehensive,
team-based care for our community. Through
these networks, patients benefit from the
combined expertise of healthcare teams
working together to help them manage their
chronic conditions.
As of 2025, ten PCNs serve residents across Singapore, with SingHealth Partners PCN being the largest, comprising 287 HSG PCN GP clinics.
Reorganisation of RHS Office to
SingHealth Office of Regional Health
(SORH)
To better meet the health and social needs
of residents, our renewed priorities are:
- Keep Well: Keeping the population well through health promotion, education and screening
- Get Well: Facilitating timely discharges and seamless transitions for patients moving from acute hospitals and specialised outpatient clinics to primary and/or community care settings
- Age Well: Helping our seniors age with confidence and ensuring they remain well-supported in the community
2019
Establishment of the SingHealth
Community Hospitals Office of Learning
(SCHOOL)
SCHOOL augments our efforts to provide
integrated health and social care for our
community. Working closely with partners
like the Agency for Integrated Care, and
Institutes of Higher Learning such as the
Singapore University of Social Sciences and
Ngee Ann Polytechnic, SCHOOL develops and
delivers valuable training programmes for
community health and social workers and
volunteers.
SCHOOL has equipped more than 1,000 learners from the health and social care sectors with skills to better serve our community.
Launch of SingHealth Community of
Practice in Social Prescribing (SCOMP)
by SingHealth Community Hospitals
(SCH)
In 2023, SingHealth Community Hospitals
introduced the SCOMP platform to foster a
dynamic and collaborative ecosystem where
health and social care providers work
together to advance social prescribing in
the community. Today, close to 1,000 health-
and social-care practitioners have joined
this community as members.
2021
HealthUP! pilot launched in
Tampines
HealthUP! empowers residents to take charge
of their health and wellbeing, working
closely with trusted partners like Sport
Singapore, the Health Promotion Board and
People’s Association. Through this
initiative, residents benefit from
personalised preventive health
recommendations, enjoy access to a wide
range of healthy living activities and
health trackers, and receive support from
our dedicated WBCs.
2022
Rollout of Mobile Inpatient
Care-at-Home (MIC@Home) services
Through this initiative, eligible patients
can receive hospital-level care in the
comfort of their own homes. The hospital’s
care team provides comprehensive care
through remote clinical monitoring, 24/7
access to the clinical team via video or
phone calls, regular home visits and home
treatment. Since 1 April 2024, this service
has been fully implemented across four
SingHealth institutions, bringing quality
care closer to home.
2022
SingHealth Centre for Population Health
Research and Implementation (CPHRI)
officially launched
CPHRI is SingHealth’s nexus for population
health research, innovation, implementation
science and evaluation. Its five strategic
themes focus on important population
segments across life stages:
- Maternal and child health, and vulnerable adolescents
- Hypertension and diabetes
- Complex needs
- Pre-frailty and frailty
- Ageing in the community
Community Ageing in Place Ecosystem
(CAPE) project, led by CPHRI in
partnership with AIC, the Housing &
Development Board and Singapore
University of Technology and
Design
The multidisciplinary and multi-sectoral
project brings together different expertise
to create supportive environments for
seniors in their existing neighbourhoods,
with an in-built process to evaluate these
ecosystems. Currently piloting in Marine
Parade and Bedok, the project addresses the
challenges of a declining old-age support
ratio through social and healthcare
integration, built environment
modifications, and strategic technology
implementation to support healthy ageing and
assisted living.
1st Asia Pacific Social Prescribing
Conference and launch of SCHOOL
Organised by SCH, the conference brought
together international social prescribing
practitioners and local population health
experts to improve social prescribing
practices and encourage more care providers
to include social prescriptions in their
care plans.
During this inaugural conference, we officially launched the SingHealth Community Hospitals Office of Learning (SCHOOL), which was first established in 2019.
2023
SingHealth Centre of Person-Centred
Care (CPCC) launched
The CPCC transforms healthcare by focusing
on a person-centric approach, aimed at
delivering health and social care that truly
matters to patients. It brings together
SingHealth’s person-centred care
initiatives, promoting this approach through
staff and patient education, while expanding
person-centred care practices and efforts
across our health system.
During this inaugural conference, we officially launched the SingHealth Community Hospitals Office of Learning (SCHOOL), which was first established in 2019.
HealthUP! officially launched
The movement has since expanded to Changi,
Simei, Siglap, Bedok and Chai Chee.
Reorganisation of Community Nurses and
WBCs into SingHealth HSG Teams, in
support of the national HSG
initiative
In July 2023, our Community Nurses and WBCs
joined forces as part of multi-disciplinary
SingHealth HSG Teams. They work closely with
Primary Care Providers and Community Care
Providers to provide place-based integrated
care right where our residents live, helping
them achieve their health goals in the
community.
2024
Family Nexus@Punggol launched
Family Nexus@Punggol is a welcoming one-stop
centre nestled within Punggol Polyclinic
that integrates health services with
navigation to relevant social services and
programmes. Families visiting the polyclinic
can easily discover and access various
health and social programmes, all
conveniently located under one roof.
Family Nexus@Our Tampines Hub
launched
A one-stop wellness hub with community-based
health and social services programmes,
conveniently co-located to support families
in the region. It also serves as a community
space for families to meet, interact and
build connections with each other.
SingHealth EatWELL Strategy
launched
The Strategy, developed from the national
EatWise framework, makes it easier for our
community to access affordable, seamless and
comprehensive nutrition care. Through this
approach, we aim to help residents stay
healthy by reducing chronic diseases and
malnutrition, while adding more healthy
years to their lives and improving their
overall wellbeing.
