Overview of Community Care Community of Practices

Background of CoP

The Community Care COP was initiated in November 2017 under the Ministry of Health (MOH) Projects. This COP formed by the Community Hospitals’ Medical Social Work (MSW) Heads of Department evolved from Community Hospital Network to a Community of Practices to focus on more professional learning and building capability.

Members of CoP

The members of this CoP are from community hospitals and past and present members are listed in the table below.

Current Core Group members

Eunice Chin Bright Vision Community Hospital
Bridget Das Ren Ci Community Hospital
Mardiana SabtuAMK-Thye Hua Kwan Community Hospital
Jasmine YongSt Luke’s Community Hospital
Cheung Siew LiSt Luke’s Community Hospital
Chua Ee ChengYishun Community Hospital
Fan Loo ChingAgency for Integrated Care (AIC)

Past members

Koh Chee WaiSeng Kang Community Hospital
Tan Pei PeiRen Ci Community Hospital
Tan Ying Yan AMK-Thye Hua Kwan Community Hospital
KT LeongSt Andrew Community Hospital
Toh Jia YiSt Andrew Community Hospital
Sherylene HeahOutram Community Hospital
Sharon WongJurong Community Hospital
Molly KohJurong Community Hospital


  • To explore and define Community Hospital Model of Care
  • To nurture junior Medical Social Workers of Community Hospitals

Current Work Plan and Progress

Community Hospitals’ Medical Social Work (MSW) Heads of Department collectively recognized the need to build standardization in assessment in order to ensure a common language and holistic understanding of the patient’s situation as a patient transit across the continuum of care in the ILTC sector, aiding the effectiveness of their intervention and integration of care. This is a first step towards achieving continuous improvement in clinical skills and building capability of Medical Social Workers in the ILTC sector.

As different social work practitioners at several institutions use various assessment tools such as InterRAI or Omaha while some use assessment tools that they have developed but may not be validated. Thus, this CoP recommends to develop a tool using Bio-Psyho-Social-Spiritual (BPSS) that will provide practitioners a systematic way of using questions in the 4 crucial and inter-related domains (biology, psychology, social and spiritual) to help practitioners, esp. inexperienced social workers who may not have the luxury of close supervision, to understand patients and their families more holistically so as to develop the most appropriate intervention plans.

The target audience of this BPSS tool are social workers, case managers and social work associates in the Community Hospitals and ILTC sector. Although the questions were first developed within the community hospital setting, the majority of the questions are applicable for nursing homes, home and day care settings as the questions were tested by several home and day care service providers.

Besides being a tool to achieve standardization, it can be used as a training and supervision tool for newly qualified social workers, social workers transitioning from the community to the healthcare setting and those new to case management. Practitioners in different settings are also welcome to customize it to better suit their setting’s needs.

Overview of Rehabilitation Project Community of Practices

Background of CoP

This group was originally initiated after the implementation of One Rehab Framework by Ministry of Health (MOH) and was explored as a cross-sector project with SASW MOH Projects. It evolved into a Community of Practices and focusing on identifying gaps in workflow and services.

Members of CoP

Since January 2019, a group of social workers from the hospitals and community came together to form a Rehabilitation Project Community of Practices (CoP). Our group consist of Medical Social Workers (MSWs) from the 3 Regional Healthcare System community settings.

Tess Hng Li JieTan Tock Seng Hospital
Jojo Yang Bin Singapore General Hospital
Lena Lye Hsiew Ling Tan Tock Seng Hospital
Tan Zhi Tong National University Health System
Christabelle He Shimin Yishun Community Hospital
Angela Chung Wai Ying SPD
Juriah Binte Ismail SPD
Carmen LokABLE
Tan Bee Hui SG Enable


The CoP members have identified supporting persons with acquired disabilities (PwAD) in returning to work as the key pain point of transitional care.

The diagram below illustrates the current state of RTW services as spontaneous, with no clear criteria to proactively screen patients for RTW suitability or to trigger a conversation on returning to work. When PwADs are being picked up by the healthcare staff for RTW, many Medical Social Workers expressed lack of understanding of the Return-to-Work (RTW) resources.

Current Project Plan and Progress

The objective of the project seeks to enhance client’s readiness and transition to work through providing early interventions and coordinating RTW services and case management. We proposed a standardized referral workflow and common form to clarify criteria of suitable clients so as to prevent inappropriate referrals and reduce administrative burden of toggling between various referral forms for RTW services.

The standardized RTW assessment form (only for social worker’s segment), a consolidated one by pulling in the strengths from various agencies, helps to set a minimal standard in social worker’s intervention and assessment of clients keen to seek RTW services.

From January 2021 to June 2021, a pilot project will be kickstarted, which includes recruiting a small group of social workers to trial the proposed workflow for RTW, usage of the standardized referral form and assessment form. We will be collecting data and feedback on the utility of the referral and assessment form, its effectiveness in channeling appropriate referrals, and the impact on the turnaround time of the referral process. The CoP also seeks to understand further gaps in RTW services to evaluate the next course of action.

Overview of Grief & Bereavement Community of Practices

Background of CoP

In 2017, a group of health and community-based social work practitioners came together and formed the inaugural grief and bereavement community of practice (CoP) in Singapore.  The CoP meets under auspices of the Singapore Association of Social Workers (SASW) and receives a three-year seed funding from the Ministry of Health (MOH).


  • To create a platform where practitioners can develop capabilities to address and respond collectively to practice challenges related to cross-sector coordination of grief and bereavement services.
  • To enhance providers’ experience of collaborative learning and practice.
  • To improve clients’ experiences of transition, ensure continuity of care and improve the level of support to clients.

Members of CoP

The CoP is made up of 45 social work practitioners from 24 health and community-based organisations. 

Singapore Hospice Council Children’s Cancer Foundation
Hospice Care Association Yishun Community Hospital
Viriya Community Services Club Rainbow
Ren Ci HospitalTan Tock Seng Hospital
Montfort CareHua Mei Centre for Successful Aging
St Andrew’s Community HospitalSingapore General Hospital
Life PointNg Teng Fong General Hospital
St Luke’s HospitalAssisi Hospice
Dover Park HospiceNational Cancer Centre Singapore
Methodist Welfare Services Home HospiceNational Heart Centre Singapore

Core Group members

Chee Wai Yee Singapore Hospice Council
Andy Sim Singapore General Hospital
Candice Tan Tan Tock Seng Hospital
Tan Yee Pin National Cancer Centre Singapore
Ng Hwee Chin Children’s Cancer Foundation
Peh Cheng Wan Assisi Hospice
Sara TanLife Point (February 2013 – November 2020)
Lok Huey Chuen Life Point
Evelyn Lai Viriya Community Services
Sandra LooViriya Community Services
Jayne Chiara LeongGrief Matters (February 2020 – February 2021)

Key Achievements and Deliverables

CoP Members meet on a regular basis to exchange best practices and engage in collaborative learning.  In each session, participants will learn the philosophy, key elements, and structure of a cross-sector CoP.   Participants will also examine the principles and deployment of open space technology to facilitate reflective learning.  Presenters will highlight the output, as well as the impact of the CoP in generating learning, transfer and application of knowledge.   Key learning points and challenges in building and sustaining a cross-sector CoP such as effective stakeholder engagement, thoughtful design and use of learning activities, timely dissemination of knowledge generated from each CoP meeting, and continuous evaluation will be discussed.

The CoP had developed a Mapping of Care Services for the Dying, their Caregivers and the Bereaved in the course of their work and will be sharing this key achievement via SASW platforms.

The CoP had since completed their journey and proposed for closure. As the CoP has current diverse and heterogenous needs, members to convene and re-engage those who are keen to form new Community of Practices in order to fulfill their needs and objectives. settings are also welcome to customize it to better suit their setting’s needs.

Care Transition Community of Practice

Renal Social Work Community of Practice