Designing psycho-social care programs for moderately distress patients at TTSH-Integrated Care Hub
Care Continuum
Care Process & Redesign
CHI Fellowship
National Healthcare Group
24 November 2025
To redesign group programs to increase participation among moderately distressed inpatients at TTSH - Integrated Care Hub. The redesigned approach shows promise in increasing participation in psycho-social programs for moderately distressed patients.
Year Submitted: 2025
Published Date: 24 November 2025
Tags: Lean Methodology, Quality Improvement, Care Process ＆ Redesign, Social Care, Intermediate and Long Term Care ＆ Community Care, Care Continuum, Social Welfare, Workflow Redesign
About this Content
Aims
To redesign group programs to increase participation among moderately distressed inpatients at TTSH - Integrated Care Hub (ICH) Level 8 and 15 from 15% to 50%.
Background
Increasing evidence shows that social factors influence 80% of overall health outcomes. The project focuses on moderately distressed patients who have low participation in psycho-social care programs.
Methods
The project involves screening patients using the Distress Thermometer and Problem List (DTPL), implementing a Stepped Care Model, and conducting Rapid Improvement Experiments to enhance program participation.
Results
Initial attendance improved from 15% to 41% after implementing new workflows and increasing program frequency.
Conclusion
The redesigned approach shows promise in increasing participation in psycho-social programs for moderately distressed patients.
Lessons Learnt
Patients are willing to be engaged with the right approach, but challenges include lack of time for team members and patient anxiety. The project is supported by various stakeholders including CHI Fellowship Program Directors and involves a multidisciplinary team.
Additional Information
This is a project under CHI Fellowship FY24.
Awarded: Jolly Good Fellow FY24.
Keywords
Integrated Care, Psycho-Social, Rapid Improvement Experiments
Innovators' Details
Innovators' Details
Healthcare Cluster(s) | National Healthcare Group |
Organization(s) Involved | Tan Tock Seng Hospital |
Platform(s) | CHI Fellowship |
Healthcare Professional Group(s) | Allied Health |
Applicable Specialty or Discipline | Medical Social Workers |
Project Lead(s) | Tess Hng Lijie |
Project Member(s) | Janet Lim |
Connect with this contributor!
Tess Hng Lijie - tess.lj.hng@nhghealth.com.sg
Project Attachment
933_TTSH_CHI_Fellowship_FY24_Designing_psycho_social_care_programs.pdf