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Our Programmes


Our programmes are designed to meet and cater to the different care needs of our population. This approach allows individuals to receive the appropriate care, and also gives us the ability to deploy resources efficiently and effectively to meet individuals’ needs.



Our programmes focus on:


  • Early detection and timely intervention
  • Caring for patients and the population in the community
  • Providing holistic and seamless care for patients across the different stages of their patient journey
  • Building capabilities in the primary care setting and the intermediate and long-term care (ILTC) settings, so that patients can receive affordable, accessible and quality care within the community
  • New care models
  • Research and Evaluation





Click here to view our corporate video.


Health Screening and Lifestyle Education

This programme focuses on health education, early detection of chronic diseases and timely interventions for those aged 40 years and above. The aim is to prevent the development of chronic diseases such as diabetes or hypertension, and/or to slow down the progression or deterioration of such diseases.


This is achieved through targeted health screening programmes for the community with referrals to appropriate interventions based on screening results.





To date, health screening programmes are available at NUHS partner GP clinics, as well as at Frontier Family Medicine Clinic and other polyclinics (Bukit Batok, Choa Chu Kang, Clementi and Jurong) in the western region of Singapore.


Appropriate-Siting of Care

This programme aims to appropriately site patients who are medically stable and do not require specialist care from NUH into the community and closer to home.


Through this programme, the care of the patients will be handed over seamlessly from the NUH Specialist Outpatient Clinics (SOCs) to a primary care partner in the community.


The key primary care partners currently under this programme are St Luke’s Outpatient Clinic and our Family Medicine Clinic – NUHS-Frontier Family Medicine Clinic (Frontier FMC).


St Luke’s Hospital is our partner for step-down and rehabilitative care.


FMCs such as Frontier attend to NUH patients who no longer require specialist care at the hospital and can be managed by primary care providers in the community.





Click here to view a video explaining the Patient-Centred Medical Home model of care adopted at Frontier FMC.


Patient Appointment Consolidation (PAC)

Our Patient Appointment Consolidation (PAC) programme helps patients with multiple chronic conditions and who are seen by two or more specialties in NUH Specialist Outpatient Clinics consolidate their appointments so that they are taken care of by ONE principal physician. This physician can either be a family physician from one of our primary care partners or a specialist from NUH.





Patients will be managed holistically, with inputs from other specialists in NUH as needed. The physician will also be supported by a multi-disciplinary team of nursing, allied health professionals and case managers.


NUHS Transitional Care

This programme aims to enable patients to transit smoothly from hospital to their homes by having a team of doctors, nurses and allied health professionals who will provide the continued care patients need in the comfort of their own homes. The Transitional Care team first assesses the patient’s needs prior to being discharged from hospital. Following which, a personalised care plan is designed based on their needs. The care plan could include education for patients and/or caregivers, medication management and referral to appropriate community resources. 





Click here to find out more.


NUHS-RHS Integrated Interventions and Care Extension (NICE) Programme

Our NUHS-RHS Integrated Interventions and Care Extension (NICE) programme aims to help patients with complex conditions who have been admitted to NUH at least three or more times a year, improve their quality of life and quality of care through holistic and integrated case management and care coordination.


A dedicated case manager will be assigned to each patient and will work with the patient’s principal physician to develop an individualised care plan that will holistically address the patient’s medical and social needs. The case manager serves as the patient’s main point of contact for assistance in navigating and receiving care from the necessary medical and social services in the hospital and community.





CareHub is a care and call centre initiative that aims to be the first single point of contact for patients after they are discharged from the hospital, so that they can continue to receive the coordinated and continued care they require. The CareHub team will also enable patients to navigate across care providers so that they receive timely interventions, where necessary.



CareHub plans to leverage on tele-health and IT enablers to enhance patients’ post-discharge care at a later phase of the programme.


Primary Care Network (PCN)

This initiative brings together a group of family doctors and community partners to create a support network for patients with chronic medical conditions such as diabetes, high blood pressure and asthma. The PCN team will develop personalised care plans for patients and facilitate access to medical, social and financial support services as required. Patients will also be encouraged to undergo health checks and educated on how to better manage their conditions.




Family Medicine Clinics (FMC)

NUHS-Frontier Family Medicine Clinic was set up in 2013 together with Frontier Healthcare Group and adopts a patient-centred medical home approach, which is primary physician led and team-based. While the primary physician manages the needs of patients holistically, he or she is supported by a multidisciplinary team of healthcare professionals.  This team-based care is also facilitated through shared medical records and the use of tele-consultations. Click here to find out more.


Keat Hong Family Medicine Clinic (KHFMC), managed by Trilink Healthcare, was set up in 2017 and is a one-stop medical facility that provides affordable, holistic and quality primary care in the community. It offers treatment options for both acute and chronic conditions. Some of its services include chronic disease management, minor treatment procedures, diabetic retinal photography and diabetic foot screening. KHFMC also provides specialised services in the management of eye conditions and a mood & anxiety clinic. Click here to find out more.


Both FMCs have a NUH-run pharmacy, where medication is dispensed at prices similar to polyclinics, and offered at a lower cost to seniors and children.


 The NUHS-Frontier FMC team



The NUHS-Trilink Healthcare team




Manpower Partnership Programme

Our Manpower PartnershipProgramme involves the cross-deployment of skilled manpower from NUHS to partnering nursing homes in the western region of Singapore so as to build capabilities in the intermediate and long-term (ILTC) setting. It aims to support ongoing efforts by the nursing homes to:


  • Build new capabilities;
  • Augment and develop nursing home services;
  • Improve care quality; and
  • Forge closer partnerships between the acute hospital and nursing home


Through this programme, NUHS healthcare workers will also have the opportunity to gain experience, greater exposure and understanding of the different care needs in the community.




Research and Evaluation

Apart from developing programmes that cater to the different care needs of the population, we are also dedicated to the continual refinement of our existing programmes through research.


The RHS Evaluation Framework serves to evaluate the effectiveness of ongoing programmes in delivering value-based, innovative and sustainable healthcare.


The Health Innovation Programme aims to define, profile and understand high cost healthcare users in NUH, with the goal of identifying and predicting subgroups of patients willing to accept interventions aimed at reducing utilisation and costs.





 For more information, please email us at nuhsrhs@nuhs.edu.sg