[POP Collect 2025] Bringing Care Closer: Community-Based Diabetic Screening
Care Continuum
Care Process & Redesign
POP Collect
National Healthcare Group
5 June 2025
To bring essential diabetic care services closer to patients and improve accessibility and adherence to recommended annual. CN-PCN plans to enhance and expand its community-based screening efforts to establish a regular schedule of screening sessions at more.
Year Submitted: 2025
Published Date: 05 June 2025
Tags: Care Continuum, Community Health, Preventive Care, Intermediate and Long Term Care ＆ Community Care, Social Care, Care Process ＆ Redesign, Access To Care
About this Content
Aims
To bring essential diabetic care services closer to patients and improve accessibility and adherence to recommended annual screenings.
Background
The Central-North Primary Care Network (CN-PCN) supports GPs in delivering affordable, quality, and timely care through community touchpoints, improving accessibility to health services.
Methods
The initiative adopts a team-based care approach with nurses and primary care coordinators providing holistic and coordinated care, complemented by on-site nurse counselling and social prescribing.
Results
From November 2023 to April 2025, CN-PCN supported 572 patients through 10 local community touchpoints, enhancing access to health services.
Conclusion
CN-PCN plans to enhance and expand its community-based screening efforts to establish a regular schedule of screening sessions at more sites.
Lessons Learnt
The initiative highlights the importance of community partnerships and a one-stop service model in improving patient management through lifestyle interventions.
Keywords
screening, diabetic, community, care, health touch-point
Innovators' Details
Innovators' Details
Healthcare Cluster(s) | National Healthcare Group |
Organization(s) Involved | Central-North Primary Care Network |
Platform(s) | POP Collect |
Healthcare Professional Group(s) | Nursing, Community Care, Allied Health |
Applicable Specialty or Discipline | General Practice, Healthcare Administrators |
Project Lead(s) | Candy Chun |
Project Member(s) | Et al. |
Connect with this contributor!
Candy Chun - Candy_Sy_CHUN@nhg.com.sg
Project Attachment
844_NHG__Bringing_Care_Closer_Community-Based_Diabetic_Screening.pdf