One-stop Integrated Screening and On-site Follow-up
Health Promotion Board (Singapore)

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
Singapore’s population is rapidly ageing, with an estimated one in five residents who will be 65 years or older by 2030, up from the current one in 11. A major concern for both the healthcare and social sectors is the increasing proportion of older adults who are at risk of developing chronic diseases, cancers and functional decline – all of which can affect their independence and quality of life. Although community-based health screening & post-screening follow-up services have been available for many years, these have not been well integrated, with screening often done in community venues, and follow-up of abnormal screening results requiring a visit to a healthcare facility. This was a navigational challenge especially for our elderly residents, resulting in poor follow-up rates post-screening. Low follow-up rates post-screening are also the likely reason for almost half the individuals with diabetes not knowing that they have diabetes despite screening rates for diabetes being reasonably good. The main reasons cited by residents for not going for follow-up post-screening were: - Cost - Inconvenience (travelling to visit a doctor) - Generally ‘feel healthy’ so don’t think that follow-up is necessary

B. Strategic Approach

 2. What was the solution?
To address this issue, the Singapore Health Promotion Board introduced the ‘One-stop Integrated Screening and On-site Follow-up’ project to integrate the various aspects of the screening and follow-up pathway. The aim was to create as seamless an experience as possible for the residents. The project provided the various screening services and many of the follow-up services (through the formation of local healthcare networks) as well as health education all under one roof in a community setting – e.g. community centres. Every year over 10,000 community-dwelling older adults go for chronic disease screening at community settings through the National Wellness Programme whose target audience is individuals 50 years old and older. Most of these individuals are eligible to go for the recommended cancer screenings and some are eligible for Functional Screening (those above 60 years). By integrating all services, residents are able to undergo recommended screenings at one go. To enhance the experience, HPB works with the constituency directors or Wellness managers to create a health carnival-like atmosphere. Because chronic disease screening requires fasting, those who are eligible for Functional and/or Cancer screenings are offered breakfast after their blood is drawn. Residents are also able to participate in fringe activities or have chats with health ambassadors and nurse educators who are present on site. Corporate partners such as those who offer optometry services and community partners such as those who offer counseling services are roped in. This means that residents who require glasses or counseling are able to immediately avail themselves of such services at no or low cost. Residents who need to see a General Practitioner (GP) for further assessment are also able to do so as a GP may be available on-site. Ultimately, this whole initiative boils down to forming partnerships and collaborations with corporates & community organisations and well as with associations who are able offer residents more than what HPB can on its own.

 3. How did the initiative solve the problem and improve people’s lives?
The “One-stop Integrated Screening & On-site Follow-up” project was designed based on the ‘needs’ of the local residents. The various services were offered at the “door-step” of residents making it more accessible and very convenient for them. The screening promoted a person-centric approach (based on an individual’s age, gender and risk profile) rather than disease-centric screening. The screening package also included on-site medical follow-up services post-screening e.g. GP consultation, eyewear prescription & dental treatment, all of which helped minimise the possible multiple trips an elderly resident might have to make to visit the different healthcare providers. The formation of local healthcare networks within the community provided a basic infrastructure for ongoing regular follow-up (where necessary) at the convenience of the residents. This is the first time that such health services were introduced to residents in an integrated yet seamless manner starting from primary prevention (healthy lifestyle education), secondary prevention (the various screenings) and also tertiary prevention measures (follow-up, intervention and community-based healthy lifestyle programmes).

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
Engaging the right partners was key to the success of this initiative. Constituency directors and Wellness managers were engaged early because of their strong knowledge of the beat on the street. They know best what the residents require as they interact with them most on various issues including health. With the needs analysis, HPB was then able to plan and solicit support from healthcare, corporate and community partners and associations such as GPs, dentists, physiotherapists, exercise therapists, optometrists, etc. sometimes, HPB also engages Health Sciences faculties of polytechnics. Once the partners agreed that they would come on board, an appropriate location was sourced for. This was normally the Community Centre which had a multi-purpose hall big enough to accommodate various activities. As Community Centres have regular activities, holding a special screening session may result in the postponement or rescheduling of some of the activities normally offered at the Community Centre. This is where the Grassroots leaders came in. They assisted in engaging the residents and generating a response to ensure a good turnout on the day of the screening activity. (Please refer to Annex A for Components of the One-Stop Screening Package) HPB built on the health ecosystem infrastructure by engaging key stakeholders - community partners, healthcare partners, and health ambassadors - to offer more affordable screening and follow-up services to residents. Key highlights of the programme include: - “Door-step” person-centric screening services - On-site follow-up - Formation of local healthcare networks - Engagement of health ambassadors - Strategic partnerships Through this multi-pronged strategy, HPB aims to address the needs of our ageing population with regard to early detection and optimal management of key disease conditions, helping our older adults to remain functional with a good quality of life, as they age-in-place. (Please refer to Annex B for the Integrated Functional Screening Solutions Framework)

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
The project team built on the health ecosystem infrastructure by engaging key stakeholders – agencies like People’s Association, Ageing Planning Office (MOH), Agency for Integrated Care; community partners like Community Clubs, local grassroots organisations and VWO partners; healthcare partners like private GPs, dentists, pharmacists and allied health professionals as well as their respective organisations; corporate partners like eyewear companies; last but not least a dedicated team of trained health ambassadors. The team recognised the need for continual engagement of the partners and through regular dialogue & networking sessions helped partners see the benefit and value of the project to the elderly residents. Great effort was put in to engage and work continually with all partners to fine-tune the work processes while obtaining regular feedback during the planning phase. This was done at regular inter-agency as well as cross-divisional meetings and with regular progress updates. After-Action Reviews were also conducted to obtain feedback that helped to further streamline work processes. The resultant SOPs were shared with partners through various channels.
 6. How was the strategy implemented and what resources were mobilized?
In 2007, the Wellness Programme (WP) was piloted by the People’s Association (PA) and supported by the then Ministry of Community Development, Youth and Sports (MCYS) and the HPB. Aimed at promoting active ageing and improving the quality of life among older adults, the Wellness Programme targets community dwelling adults aged 50 years and above. The Wellness Programme has acquired funding to conduct health screening in all 87 wellness sites until 2015. On-site counseling by HPB nurse educators is available as well as the 12-week exercise programme Strength Training Exercise Programme (STEP), which is a follow-up for those who are identified as having low physical function after being screened for functional decline. The cost of screening on-site per resident is S$135 assuming that each resident is eligible to undergo all the available screening tests i.e. screening for chronic diseases, selected cancers and functional decline. The cost of STEP is S$400 per resident. For the on-site follow-up solutions, HPB works with community organisations and associations who volunteer their services for free. Corporate partners sponsored items as well which could aid in interventions. Some may levy charges but the cost to the resident is minimal. General Practitioners and Allied Health Professionals are offered honorariums. This together with the cost of transporting of equipment and logistics, brings the the total cost of organising one-stop screening and follow-up targeting 100 residents per session, at a community centre in Singapore is approximately S$20,000 .

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
A good measure of a community event is the size of its outreach. To achieve the targeted number, the programme must be attractive enough to get people to come. Residents should also be able to see the benefits of the programme. Partnerships and collaborations with private and public organisations contributed to good results for this programme : - Easy access to screenings for residents. Residents did not have to travel to get their screening done at a clinic or medical centre. - Affordable screening and follow-up - Good turnout for activities and services because of accessibility and affordability as well as the more appealing atmosphere (less clinical, more social). - Residents were among their peers – their friends and neighbours who were going for the screening, as well as health ambassadors from their neighbourhood who were available to guide them and address queries or concerns - Immediate access to most of the prescribed interventions - Pooling of resources; efforts are not duplicated or wasted, resources were maximised

 8. What were the most successful outputs and why was the initiative effective?
Other than an outreach number of 1,000-2,000 per event depending on the scale and a screening target of 100 persons per session, the following measures were put in place to monitor progress: - Follow-up phone calls by screening providers for participants found to have abnormal readings - Records by on-site healthcare professionals who provided the follow-up (e.g. on-site dental treatment records, referral records by optometrists) - After action reviews with the community partner after the one-stop integrated screening and follow-up event. - On-ground feedback from residents

 9. What were the main obstacles encountered and how were they overcome?
The key challenge in putting this project together was the engagement and buy-in of the key stakeholders from the various agencies and organizations to organise this programme. The team tried to overcome the obstacles by building on existing community infrastructure. The team also faced challenges in getting healthcare professionals to volunteer due to their time and work commitments, or general lack of interest. To overcome this, small honorariums were provided to healthcare professionals, to help offset their transport and meal costs for their voluntary efforts. Lastly, as much as HPB tried to bring in all relevant forms of follow-up help, not all solutions could be provided on-site each time. For example, the dental bus on-site could provide basic dental treatment such as scaling, polishing, tooth extraction and filling but could not cater for more complex treatment such as root canal treatments and making of dentures. The on-site GP could provide free medical consultation and assessment, but did not have access to the patients’ full medical history records to do a comprehensive evaluation. The doctor also could not provide any forms of further medical assessment nor prescribe medication on-site. In an attempt to overcome this, the team built dentist and GP networks within a 2-kilometre radius of the screening site, and offered participants the contact list of the participating clinics that they could go to for further follow-up and assessment. However, being seniors with low health literacy, some participants were subsequently lost from the system. HPB has since trained Health Ambassadors to do follow-up calls for such participants, to encourage them to go for their further assessments and follow-up.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
This package provided screening, on-site medical follow-up and health education services all under one roof making it accessible and convenient for the residents. Key partnerships with the 3P sectors helped to further off-set the costs of these services and reduce 'out-of-pocket' expenses for the elderly thus making screening & follow-up more affordable. Post-screening intervention programmes and ongoing educational activities within the local community has also helped improve seniors’ health literacy. Working with the grassroots and social partners in health activities has helped seniors integrate with the community, moving closer towards our goal of achieving ‘ageing-in-place’ for older Singaporeans. The project addressed key challenges in the screening pathway namely accessibility, affordability and convenience. The impact was measured by whether there was a significant difference in person-centric screening rates (i.e. an individual having gone for all the recommended screening based on his age and gender) and post-screening follow-up rates. In addition, qualitative on-post-event feedbacks were collected from participants on ground.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
The model is being extended and offered to all 87 constituencies in Singapore, including all 87 Wellness Programme sites. There are funds available to support the programme until March 2015. Subsequently, HPB will have to apply for additional funding after programme evaluation. Because of the nature of the programme which required a lot of physical resources and coordination to implement, one model that could be explored is to get grassroots organisations to own the programme. Through capacity building, HPB hopes to inculcate in the grassroots and community leaders the benefits are of early screening, the importance of follow-up and having community-dwelling older adults living independently within their communities for as long as they are able to rather than institutionalised. HPB is also working with the six regional health systems to integrate, synergise and focus resources for regional and community health promotion. With strong involvement from NGOs or Voluntary Welfare Organisations as well as strong partnerships with the private sector, this programme can be replicated and sustained.

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
This project served as a very good learning journey in helping to co-create and co-implement health promotion initiatives with partners as well as build their capacity in helping them sustain our efforts in the community. The project was a success only because of the teamwork across inter-agencies. The project team built on the health ecosystem infrastructure by engaging key stakeholders, such as People’s Association, Ageing Planning Office (MOH), Agency for Integrated Care; community partners like Community Clubs, local grassroots organisations and VWO partners; healthcare partners like private GPs, dentists, pharmacists and allied health professionals as well as their respective organisations; corporate partners like eyewear companies; last but not least a dedicated team of trained community health ambassadors.

Contact Information

Institution Name:   Health Promotion Board (Singapore)
Institution Type:   Government Agency  
Contact Person:   Akila Andiappan
Title:   Dr  
Telephone/ Fax:   6435 3247
Institution's / Project's Website:  
Address:   Health Promotion Board, 3 Second Hospital Avenue
Postal Code:   168937
City:   Singapore
State/Province:   Singapore

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