top of page
  • Lin Yongqing

Care coordination is hard. What are we doing to help?

Typically, staff from different organisations do not share patient information with each other. They may be aware that their patient is seeing another service provider, or may even make the referral themselves. But beyond that, data protection regulations and the lack of an integrated coordination platform mean that they rarely talk to one another, even though they may all be working towards the same goals for the same patient – improving the patient’s health and well-being.

Cartoon by author Lin Yongqing

Former Clinic Director of Marine Parade Polyclinic, the late Dr Agnes Koong, had a different idea of how health and social service organisations should work together. As someone who was sincerely devoted to serving the community, her special focus was on the vulnerable members of our population – the elderly, and those struggling with multiple medical and social issues.

Her brainchild, the Primary Care Based Integrated Community Care Teams programme (abbreviated to PACE-It), brings together a single care team comprising colleagues from across health and social sectors: SingHealth Polyclinics (Marine Parade), SingHealth Community Nursing, Changi General Hospital (CGH) Neighbours for Active Living, and Montfort Care, with the aim of improving the patient’s care experience, as well as giving them the tools and motivation to manage their conditions.

"I always told Dr Agnes that the success of the programme is due to her work. She was always accessible to us, she made things happen, and this is what we needed to get our clients through the system. Her passion in driving shared care for patients has benefitted many in the community." - Ms. Cheryl Lau, Senior Community Manager, CGH Neighbours for Active Living
"Dr Agnes' vision has truly inspired us to come together as a village to minimise touchpoints and work towards a singular care plan for clients with complex needs. This has greatly strengthened the network of support for clients, and most importantly, aided us in working side-by-side with them in achieving their goals.” - Ms. Josephine Quek, Assistant Manager (SRN), GoodLife! Marine Parade, Montfort Care

A patient in this programme consents to being enrolled to all four service providers, which meet regularly for multi-disciplinary team discussions, and put together a shared care plan that patient and care team jointly work to carry out. Each organisation has a distinct role: a doctor from Marine Parade Polyclinic would lead the team and be in charge of the patient’s medical care; a case worker from Montfort Care would ensure that the patient’s social issues were being managed; a Community Nurse would provide health coaching and chronic disease monitoring to empower them on self-management; a CGH Neighbours care coordinator would keep track of all referrals, and close any gaps in care; and lastly, a polyclinic nurse would act as the case manager and coordinate the whole asynchronous care delivery process.

However, with the offices of each organisation scattered across the Eastern region of Singapore, from Marine Terrace to Upper Changi Road, and with the SingHealth partners using different systems from Montfort Care, there was the question – how would they all communicate with each other?

This is where MOHT came in. Led by Ms Christina Oh from the Future Primary Care programme, a Lean Six Sigma Black Belt holder also trained in design thinking principles, the PACE-It team came together to understand each other’s care processes and share what was needed for their collaboration to work. The process was guided, where multiple care flows were studied in depth, with the aim of converging at the best care for the patient. It was important that every party understood each other’s role and contribution to the patient’s health and social well-being. This set the tone on how duplicated processes could be trimmed and sharpened in order to achieve the best outcome for the patient.

Representatives from SingHealth Polyclinics, SGH Community Nursing, CGH Neighbours for Active Living, and Montfort Care gather at the MOHT premises for a design thinking workshop for PACE-It


Understanding each other’s needs and feedback in real-time was also vitally important. There needed to be a way for SingHealth partners to communicate and share patient information with Montfort Care and vice versa; for all partners to view the shared care plans they had agreed on; and for every partner to record and share the tasks they had performed for the patient.

In December 2020, in partnership with Activate Interactive and Integrated Health Information Systems (IHiS), MOHT launched the PACE-It mobile app, which was designed to the specifications of the multidisciplinary care team. The app allows users to contribute to and share a set of just 70 key data fields with each other (curated and streamlined from the 530 data fields previously collected across all four organisations), and provides a secure chat platform, a shared task calendar, and live editing of care plans.

Wireframes for PACE-It mobile app


"It is heartening to see the public-private collaboration to make the app secure as well as user-friendly in a very short time. Kudos to the team for the great teamwork!” - Clin A/Prof Ang Seng Bin, Clinical Lead, MOHT

As care team members started to use the app for the management of patients, the PACE-It team realised that changes needed to be made to support the ways that real users were working. MOHT has been continually making updates to the app based on the feedback of the care team, with users now on version 1.0.5.

The PACE-It partners agree that the multidisciplinary team approach pioneered by Dr Koong and supported by MOHT’s mobile app has helped them improve patient care.

Said Dr Hu Pei Lin, the current Clinic Director of Marine Parade Polyclinic, “PACE-It has brought us so much closer to our partners and our patients. The passion, energy and ideas of our partners have been really inspiring. We have a common goal to improve the health and social well-being of our clients, and PACE-It gives us the framework and communication platform to do that with.”

Other PACE-It members add that there has been faster communication between partners, and that the new approach has allowed them to work closely with partners to problem-solve together. Mr Nasrifudin bin Najumudin, a nurse clinician from SGH Community Nursing, said, “PACE-IT enhances the great partnership our Community Nurses and Montfort Care have developed over the years to care for residents. The app enables us to connect with each other and other partners quicker, [and] to look out for potential social factors that may affect how patients manage their medical conditions.”

Patients have also noticed the differences before and after PACE-It.

Ms Cheryl Lau, Senior Community Manager with CGH Neighbours for Active Living, observed, “The patients say that it’s good that so many people from various care providers are focused on helping and caring for them. It’s a miracle, to be able to build such a unique relationship [within the team]; it’s a special thing.”

The PACE-It pilot will run until December 2023. Parties interested in learning more about our technology-enabled model for care coordination may contact the project manager ([email protected]) for more information.


MOHT is grateful to the leadership and vision of the late Dr Agnes Koong, who passed away from leukaemia on 6 September 2021. She is deeply missed by members of the healthcare family, as well as the communities that she served.

Back to MOHT Blog

bottom of page