PI: Ad Maulod
Project Period: 2020-2022
Background & Rationale
As Singapore shifts towards a population health approach with ageing-in-place as a key priority, developing structures and processes primed towards preventive care and care integration is crucial for the continuity of care for older adults. Large-scale eldercare operators like THKMC can leverage on their multi-service infrastructure to provide care integration, bolstered by the rapport and familiarity clients have already established within THKMC.
Aims
The project evaluated THKMCs existing services, with the aim of developing an integrated care model for its older clients as they move through the spectrum of preventive care to more intensive care in the community.
Methods
The evaluative study utilizes a participatory action research (PAR) approach to inform the evaluation and development of an integrated geriatric care model (IGCM) at THKMC. Qualitative methods of data collection: participant observation, in-depth interviews, focus group discussions and group model-building exercises.
The data collection process was divided into three main components with three different groups of stakeholders, namely THKMC senior management (n=11), service providers in the form of THKMC staff (n=66) and service users in the form of THKMC clients (n=95) and their caregivers (n=15).
Key Findings & Implications
Older adults, most in their 70s and living alone in one-room rental flats, described struggles with chronic pain, difficulty carrying groceries or doing housework, and constant worries about falling at home. Nearly half said their income was not enough to cover monthly expenses, even with financial aid, and some admitted to skipping meals. Loneliness was another recurring theme—neighbours moving away or strained family ties left many feeling isolated and anxious. Caregivers, who were often older themselves, worried about their own health as they tried to provide support, for example feeling too weak to safely shower a spouse or parent.
Service providers echoed these concerns. Frontline staff noted that while many older adults have medical issues, their most pressing needs are often social—loneliness, financial stress, family tensions, or low mood. They described the difficulty of meeting these needs within rigid service guidelines, and the strain of managing high caseloads. Staff also highlighted challenges with fragmented systems: information is not always shared across teams, services can feel siloed, and clients sometimes receive overlapping or mismatched support. At the same time, providers and caregivers agreed that when services are well coordinated—such as home nursing working hand-in-hand with personal care, or staff linking clients to befriending and counselling—the impact is much greater. This points to the importance of clearer communication, stronger collaboration, and care that looks beyond survival to helping older adults live with dignity, connection, and confidence in their communities.