Blending Care, Building Community: A Novel Approach to Improving Health Outcomes in Singapore's Aging Population

Abstract

Background: Health and social care fragmentation remains as a serious and systemic issue in Singapore. Limited information sharing and coordination between healthcare and social care providers, different funding streams, and the lack of care ownership hinder care continuity across different settings. Such care fragmentation creates gaps in follow-up which have been found to increase system utilisation due to unmet psychosocial needs and poorer health outcomes. Therefore, there is an urgent need for innovative approaches to better integrate care and delivery.   Approach: The Blended Care Team (BCT) is a community-embedded team comprising both health and social care professionals, supported by community volunteers. This new model of care is implemented in a part of Western Singapore. The team provides targeted interventions for residents aged 40 and above, with three key focus areas: preventive health, chronic disease control, and frailty management. The BCT's multifaceted approach aims to improve residents’ physical, mental, and social well-being. This is achieved through proactive outreach, personalised health assessments, and targeted chronic disease and frailty management. The team utilises a physical community space, "Happy Village @ Mei Ling," which serves as a central hub for health promotion and community building activities.   Results:Preliminary insights from our evaluation study suggested that relationship built with residents improve adherence to health interventions and promote positive behaviour changes. Adherence to interventions were also promoted through social connections forged between participants during exercise. Participants reported increased confidence in managing their health and better physical vitality. The integration of social and health services enables a more comprehensive approach to address the social determinants of health including social isolation and limited access to resources. This model demonstrated significant potential in building community trust and thus improving health outcomes such as chronic disease control, frailty status, health perceptions, and in the longer term, healthcare utilisation.     Implications: The BCT model offers several key learnings. Firstly, it demonstrates the importance of community embeddedness in health and social care delivery, particularly for aging populations. Trust built between residents and the care team helps to catalyse positive health behaviours. Secondly, integrating social and health services creates a more holistic approach to managing well-being. This integration addresses both medical and social determinants of health simultaneously. Thirdly, the model's flexibility in tailoring interventions to different frailty levels provides a valuable template for personalised community care for residents across all health statuses.   Looking ahead, this model presents a scalable approach that could be adapted to diverse urban settings globally. Its emphasis on prevention and community engagement aligns well with international health priorities for aging populations. The next phase involves several strategic steps: expanding the model to additional neighbourhoods, conducting comprehensive long-term impact studies, and refining engagement strategies for diverse communities. In conclusion, the BCT model represents a promising pathway to promoting health and well-being through integrated community-based care within and beyond Singapore. By blending healthcare with social support and leveraging existing community resources, it offers a sustainable pathway to improve health outcomes and quality of life for aging populations.