Community-based model of care in Bukit Batok to expand to other parts of Jurong

SINGAPORE - Every day, Madam Zaiton Aziz, 61, makes sure her husband takes all 12 of his medications. She also helps him with peritoneal dialysis for his kidney failure, which has to be done four times a day at home.

This has been her routine in the past few years since her husband, Mr Mohamad Amin Kasdori, 62, suffered multiple strokes. He has chronic conditions like diabetes, as well as high cholesterol and high blood pressure.

Caring for her husband took a toll on the petite woman, who ended up with a slipped disc and underwent spine surgery in 2022. 

“It is challenging. He relies on me for everything... and he seems to have symptoms of dementia, like being quite forgetful, repeating questions and not being able to control his moods,” said Madam Zaiton, a school bus attendant.

A 2019 meeting with Ms Katherine Tan, 54, one of five care connectors from Ng Teng Fong General Hospital (NTFGH), has helped Madam Zaiton view life more positively. 

Ms Tan’s role as a care connector is to engage residents in Bukit Batok to help them stay healthy and to link them up with community health and social support programmes if necessary. She also shares with them information on health screenings and vaccinations. 

With Ms Tan’s help, Madam Zaiton applied for a grant to attend the home-based Caregiver Training course coordinated by the Agency for Integrated Care, so that she could better care for her husband. She also applied for the Home Caregiving grant, which helps cover some of his medical expenses.

Encouraged by Ms Tan to prioritise her own health, she went for breast and cervical cancer screenings and flu vaccination.

“Katherine and I are friends, and when I have any problems I will call her,” said Madam Zaiton.

More than 500 residents like her have benefited from such support under a community-based model of care funded by JurongHealth Fund that began in 2018. The six-year programme – known as the Bukit Batok Township Model of Care – was born out of a partnership between Bukit Batok constituency and NTFGH. 

From June 2019 to March 2023, the team reached out to more than 22,000 residents across 11 blocks in Bukit Batok. 

Ms Tan said: “We knock on many doors and sometimes people don’t open their doors or reject us. Even after we share about the benefits of health screenings, they are not interested.

“The way to reach many people is not to keep telling them to go for vaccinations, but to first build relationships with them and get to know them better... When they’re closer to you, they will be more open, and it’s easier to encourage them.”

Some initiatives under the programme will soon be extended to other parts of Jurong such as Hong Kah and Bukit Batok East. 

More complex cases are discussed by an interdisciplinary group made up of general practitioners and community partners, to manage different needs, from financial assistance and regular health screenings to mental health support. 

The positive outcomes of this model of care are recorded in a commemorative book that was launched on Saturday at a health carnival organised by NTFGH and Bukit Batok SMC.

Ms Lee Hee Hoon, NTFGH’s director of allied health and community operations, said residents reported a significant improvement in their health-related quality of life a year after joining the initiative, especially for those aged 60 and above. 

Take-up rates for cervical cancer and colorectal cancer screenings and influenza and pneumococcal vaccinations, among others, have also improved since 2019. 

Social support is just as important as medical care, said Ms Tan. “Most of the older residents have chronic diseases and are already taken care of by doctors, but any social issues they face are less well known.” 

“Some of them isolate themselves in their homes. Through this outreach, we get to know if they need any support; we encourage them to go to Active Ageing Centres, exercise and make friends.” 

Madam Zaiton is one who has adopted a healthier lifestyle, doing brisk walking and hiking with friends on the weekends, and going for Zumba classes. 

“I’m learning how to have self-care. When I feel fit, I can take better care of my husband.”