One Care Plan (OCP)
16 July 2026
One Care Plan is a provider-to-provider digital tool built on a minimum data set that enables multidisciplinary providers across care settings to share patient information and care plans. This supports better coordination of care for patients with complex health and social needs.
One Care Plan was jointly developed by MOHT, Synapxe and SingHealth, with inputs from NTUC Health, Thye Hwa Kuan Moral Charities, Home Nursing Foundation, St Luke’s Hospital and iCARE-Primary Care Network.
Aim Statement
To enable providers from primary care, hospital, community and social services to access and contribute relevant patient information, align on care goals, and collaborate more effectively for patients with complex needs.
Why It Matters
Singapore’s ageing population and shift of care into the community make coordination across care settings increasingly important. For patients with complex health and social needs, fragmented information across providers can limit visibility, create duplication and make it harder to maintain a coherent care plan. OCP tests how a shared digital platform could support cross-setting care coordination in real-world workflows.
Summary
Population: Patients with complex health and social needs, along with the health, community and social care providers supporting them.
Intervention: A single, shared care plan accessible across care providers, enabling them to both obtain and contribute relevant information, align on care goals, and collaborate on patient needs.
Comparator: Usual care coordination via traditional fragmented channels such as emails, calls and standalone systems.
Outcomes: Improved shared visibility, more coordinated care planning, reduced duplication, and stronger provider confidence in cross-setting collaboration.
Key Achievements
Scaled implementation across care settings
Successfully launched OCP in October 2023, starting with SGH’s Empowered Communities of Care (ECoC) programme
Onboarded 272 users, supporting over 526 patients across programmes including (ECoC) and Primary Care Based Integrated Community Care Team (PACE-It)
Demonstrated value in real-world workflows
Engaged five Public Healthcare Institutions and 15 Community Healthcare Providers
60% of users reported being able to leverage cross-setting data, 75% said they would recommend OCP to others, and 100% found OCP useful in supporting their work
Iterative product development aligned with on-the-ground needs. Four major product iterations were implemented throughout the product lifespan in response to user requests by users, ensuring a better fit for their unique needs. Enhancements included:
Revamp of patient dashboard and progress notes
Inclusion of new assessment framework unique to each institution
Automatic retrieval of hospital admissions, discharge summaries and patient appointments
Revamped consent-taking notifications and aligned consent workflows with on-the-ground processes