Year 2021
September 2021


Abstract Title
Strong partnership between hospital and community partners can help to achieve positive clinical outcomes among patients from lower socio-economic backgrounds.



Institute of Mental Health1

Background & Hypothesis

A lack of social support systems is usually prevalent among those from vulnerable socio-economic backgrounds, which can be a significant exacerbating factor affecting their clinical outcomes. To provide strong post-discharge support in the community for such patients, the Institute of Mental Health (IMH) and Agency for Integrated Care (AIC) piloted the ‘Aftercare Programme’ in 2015. The aim is to provide continuity of post-discharge care by the psychiatric case manager and community partners to produce positive clinical outcomes among patients.


Clinical outcomes consisting of outpatient clinic default rates, unplanned emergency room visits, and hospital admission rates were measured among 35 residents residing in a 1-room HDB rental block in Singapore. Outcomes were measured per cohort year recruitment (2015, 2016, 2018,2020) by comparing clinical outcomes a year before the patients’ enrolment to the Aftercare Programme, and a year from the time they were enrolled. All interventions put in place were done concurrently and included: home visits, ensuring compliancce to medication and appointments, and supportive counselling.


There was a total overall decline in outpatient clinic default rates (17.3%), unplanned emergency room visits (18.18%), and hospital admission rates (5%) among the cohorts. This illustrates the positive impact that strong community partnerships have in improving patients’ clinical outcomes.

Discussion & Conclusion

The results show that a strong partnership between the hospital and community can have positive effects on improving patients’ clinical outcomes, even just a year into implementation, by mitigating the gap where a lack of social support is usually present.