Person-centered Needs Assessment for a Regional Population in the North of Singapore Using a Population Health Survey

Background: Yishun Health (YH), a regional population health system under Singapore’s National Healthcare Group expanded its role beyond healthcare provision, to care for more than 330,000 residents in northern Singapore. This prompted transformation towards a more effective and sustainable Unified Care Model (UCM). YH adopted a value-driven strategy, involving needs-based population segmentation, segment-specific interventions, and systematic measurement, to accelerate this integrated care transformation. Better understanding of our population’s health needs was required to support effective needs-based population segmentation and to enable service planning. Methods: A person-centered Needs Assessment Framework (NAF) was developed to assess resident needs across “My Body", "My Mind & Networks", "My Self-Care" and "My Living" domains. A YH Population Health Survey (PHS) anchored on the NAF was conducted in 2022 to collect comprehensive needs data about our population. PHS2022 is a mixed-method study that comprises quantitative household interviews of randomly selected residents served by YH, and qualitative focus group discussions among purposively selected respondents. Survey sample was weighted to be representative of residents in northern Singapore, and descriptive analysis was conducted using SPSS Statistics v27 to establish population baseline status of NAF needs areas. Results: With a 61% response rate, 2499 residents aged ≥18 years old participated in the household interview. PHS2022 results provided resident needs and health status baseline for 26 needs areas. Under “My Body”, 20.4% of residents reported needs related to pain/discomfort. Besides oral health, residents aged ≥80 years old reported highest needs under “My Body”. Females reported higher needs under “My Body” than males. Under “My Mind and Network”, half of the caregivers reported caregiving-related needs, more frequently among female caregivers (47.8%). Residents aged 18-39 years old reported highest relationship-related needs (11.7%). Prevalence of needs related to caregiving, mental health and abuse were highest among Malays. Residents living in 1-room and 2-room public housings reported more needs under “My Mind and Networks”. Under “My Self-care”, half of all northern residents reported needs related to nutrition, sleep and rest, screening, vaccination, and exercise. These needs, along with medication-related needs, were most prevalent among elderly aged ≥80 years old. Needs related to sleeping and rest (60.3%), binge drinking (9.3%) and cigarette use (16.0%) were most prevalent among younger residents. Under “My Living”, 12% of residents reported income-related needs, which were higher among older residents and Malays. Discussion: YH PHS2022 is the first population health survey conducted by a regional population health system in Singapore which provided detailed understanding of our population’s health needs, enabling needs-based population segmentation and more targeted integrated care services planning. Comprehensive and representative measurement of population needs, and health status from YH PHS2022 provided a baseline to kickstart healthcare services integration journey. YH services models and care processes can be better prioritized and integrated to address the population’s unmet needs and thereby achieving better population health outcomes. YH PHS2022 is a critical initiative to enable UCM evaluation and overall effectiveness of our integrated care and health system transformation efforts.