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An Integrated approach to dementia care in a Community Hospital in Singapore


Jasmine Yong ,

St Luke's Hospital, SG
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Siew Li Cheung,

St Luke's Hospital, SG
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Kamun Tong,

St Luke's Hospital, SG
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Jean Lim,

St Luke's Hospital, SG
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Lee Lian Phua,

St Luke's Hospital, SG
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Cindy See,

St Luke's Hospital, SG
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Sarah Lim

St Luke's Hospital, SG
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Introduction: Singapore has 40,000 Persons with Dementia (PWD) and this is projected to reach 53,000 by 2020, and 187,000 by 2050. There is a need to support the community care of PWD vis-à-vis institutional care.

Singapore’s Ministry of Health (MOH) funded theDementia Care Project (DCP) in St Luke’s Hospital (SLH) in 2013. SLH is a Community Hospital which provides inpatient and outpatient rehabilitation, respite care and home care services. DCP aims to deliver integrated care for PWDs and their caregivers through a mobile multidisciplinary team with holistic assessments, interventions and psychosocial support to meet the needs of PWDs and caregivers. 

Short description of practice change implemented: PWDs are recruited into the DCP which provides integrated and coordinated support for PWDs and their caregivers from inpatient and into the community. Roles are defined with the doctors focusing on diagnosis and pharmacological interventions; nurses conducting cognitive assessments and caregiver training; therapists teaching caregivers on engaging PWDs; social-workers providing psychosocial support and financial assistance; nursing trained care-coordinators monitoring PWDs after discharge and providing caregivers support in the homes.   Monthly meetings to discuss patients, with regular interdisciplinary teachings are conducted to strengthen the integrative care model. 

Aim and theory of change: DCP aims to help PWDs remain well in the community after discharge, and to provide caregiver support. This is achieved through the holistic assessments and interventions by the multidisciplinary team in a coordinated manner.

Targeted Population and Stakeholders: The target population, PWDs and their caregivers admitted into SLH. Stakeholders include the multidisciplinary DCP team and community service providers.

Time Line: MOH funding for this project was from June 2013 and will end in April 2017.

Highlights (Innovation, Impact and Outcomes) The DCP integrated care for PWD and their caregivers across disciplines, from inpatient, and into the community. Clear defined roles, patient-centred practice, regular multi-disciplinary discussions and training resulted in holistic management, client satisfaction, and good outcomes for PWDs. 

Comments on sustainability: The integrated mobile team concept allowed a wider reach with reduced funding and valued outcomes. 

Conclusions (Comprising Key findings) A total of 444 inpatients were recruited from June 2013 to Mar 2015.

The DCP consistently achieved high caregiver satisfaction rate, with improvement in caregiver distress and in patients’ Modified Bartel Index.

                                                                        Year 1                       Year 2                          Year 3

                                                             Jun 13 to Mar 14        Apr 14 to Mar 15        April 15 to Mar 16

No. of Inpatients recruited                                 143                            162                           139

No. of Outpatient Medical Attendance                 277                            426                            508

Improvement in behaviours of PWD                    67%                           70%                          63%

(Neuro-psychiatry Inventory - NPI)

Improvement in Caregiver Distress (NPI)            53%                           67%                          68%

Modified Bartel Index (MBI) Improvement           78%                           84%                          78%

Caregivers Satisfaction                                      95%                           93%                          95%


Discussions / Lessons Learned: Clarity of roles, centred around the PWD, with efforts on coordinated care and learning is paramount for better outcomes. This model can support patients while in hospital and also in the community. This is necessary given the rising number of dementia patients in our future.

How to Cite: Yong J, Cheung SL, Tong K, Lim J, Phua LL, See C, et al.. An Integrated approach to dementia care in a Community Hospital in Singapore. International Journal of Integrated Care. 2017;17(5):A575. DOI:
Published on 17 Oct 2017.


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