ADB Social Protection Week: Session 9A

Enabling Ageing In Place Through a MultiSystems Grounds Up Approach:

The Community for Successful Ageing

Project
Peh Kim Choo
Tsao Foundation
August 2016
DISCLAIMER: This presentation does not necessarily reflect the views of ADB or the Government concerned, and ADB and
the Government cannot be held liable for its contents.

THE CONTEXT AND CHALLENGES

The Changing Demography and Its Impact
- the exponential increase in the numbers of
elders especially the old-old groups

- decreasing birth rates

The Changing Profile of Families and Life
Style

Fragmented Service Delivery Systems

An Outdated Mindset?

Tsao Foundation. No unauthorised reproduction.

WHAMPOA
Number of residents older
than 60 years = 5,500
(18% of total population)
Housing type:
HDB 3 room flats or smaller - 49%
4-room HDB flats - 33%
5-room flats and bigger - 18%
7 precincts
Currently expanded to 9 precincts
with an additional 10,000 residents
of which 2000 are 60 and above
2015. Tsao Foundation. Not to be reproduced or disseminated without permission.

The ComSA Structure

Care System
(Delivery &
Self Care)
Community
Development
(mindset &
engagement)

Infrastructure
Development
(integrating
housing &
services)

2015. Tsao Foundation. Not to be reproduced or disseminated without permission.

THE ComSA COMPONENTS USING PUBLIC

HEALTH, PREVENTIVE, LIFE COURSE
COMMUNITY APPROACH
Housing and
Transport
Infrastructure and
neighbourhood
Long-term care
facilities in stealth
Person-centred
universal design
Food, shopping and
recreation

ComSA

Care
Management
System
Patient-centred
Medical Home
(Primary Care)

Community
Development

COMMUNITY
GERI CENTER

Community Assesment
Capacity Building
Outreach and engagement

Tsao Foundation. No unauthorised reproduction.

Evaluation
Process
Outcome

Risk Screener
Risk
Stratification
Care
Management
Primary Care
Service
partnership and
volunteers

ComSA@Whampoa

Older People
Health Risk
Assessment

Population Segmented Across the Spectrum of Health Risk

High

Low/
Moderate

Disease Specific Risk Assessment

PCMH

Care Management
Population Based Health Management

Healthy
Disease
Prevention

Health
Promotion

SCOPE, Self Care

COMMUNITY DEVELOPMENT
Self Care and Wellness
Interest Groups (e.g.
SCOPE)
Community Senior
Health Champions
Community Health
Partners
Community Outreach
and Engagement
Shifting community
perception

Participation

Engagement

2015. Tsao Foundation. Not to be reproduced or disseminated without permission.

AgeFriendly

MAJOR MILESTONES
A validated community risk screener and risk
stratification algorithm
A care management system catering for simple to
complex care needs
A volunteer para-care manager management system to
support the care managers
A service partners network
An advanced primary care model for complex, frail
elders and their families
In progress a CC-based community geriatrics center
with advanced primary care clinic, care management,
center based care, active ageing hub with behavioral
medicine component
Program Evaluation (process and impact) in
conjunction with NUS SSH SPH
2015. Tsao Foundation. Not to be reproduced or disseminated without permission.

THANK YOU