Health-related needs and care planning for community-dwelling residents through a Community Nurse Post in Singapore: a descriptive study.

Background: Community nurse posts (CNP) were set up over various locations in Singapore to provide accessible early health assessment and healthy lifestyle advocacy for community-dwelling residents. These CNPs were embedded within Active Ageing Centre (AAC) that offer health and social activities, befriending support and care coordination services. This place-based nursing care provision, through collaboration with community partners, form Community of Care (CoC) networks which aim to enhance health and social care harmonization beyond the walls of the acute hospitals. While this network supports community-dwelling residents to age well and age in place, more needs to be understood on the common health and care needs of the residents and the role of the community nurses in addressing these needs. Aim: This descriptive study aims to explore the needs of community-dwelling residents and the role community nurses play in addressing residents’ health and care needs through collaborations with community partners. Method: A chart review was conducted on healthcare records that were entered into a data collection form in Microsoft Excel after CNP reviews across the region of Toa Payoh, Singapore between August 2022 to March 2023. Residents who provided verbal consent to attend CNPs received 6 monthly health and wellness review, health education and care coordination services. Information was drawn from the documented collaborative care plans developed using the Omaha System (OS) standardised taxonomy. The data was examined and exported into IBM Social Packages for the Social Sciences (SPSS) software for descriptive statistical analysis. Content analysis of free-text documentation was conducted to identify key care interventions performed by the community nurses. Results: A total of 73 medical records were reviewed. The majority of the residents were very mildly frail with Clinical Frailty Scale (CFS) of 4 (n=70, 42.9%) and a mean age of 77.49 years (n=71). Top five identified OS problems were namely 1) Musculo-Skeletal Function (n=36, 50.7%), 2) Circulation (n=20, 28.2%), 3) Cognition (n=15, 21.1%), 4) Medication Regimen (n=20, 28.2%) and 5) Nutrition (n=25, 23.9%). The most utilised OS interventions for the common problems were ‘Teaching, Guidance, and Counselling’ (n=101, 53.2%), ‘Case Management’ (n=62, 32.6%), Treatment and Procedures (n=15, 7.9%), and Surveillance (n=12, 6.3%). Content analysis of qualitative data highlighted the following themes, 1) ‘fall prevention education’ and ‘referral to therapist’, 2) ‘hypertension management education’ and ‘red flags recognition and escalation’, (3) ‘encourage social engagement’ and ‘reinforcement on medical appointment compliance’, 4) ‘reinforcement of medication compliance’, ‘adopt pillbox utilisation’, ‘care coordination with community resources’, 5) ‘healthy diet advocacy’ , ‘advice on nutritional supplement’ and ‘referral to dietician’. Conclusion: Our study outlines the common health-related issues faced by community-dwelling residents, as well as the diverse roles and tasks performed by Community Nurses in addressing these needs. These nurse-led interventions in a place-based care model reflects the potential for more collaborative strategies with community partners to support residents in managing their health and well-being. Further exploration on the impact of community-based nursing care provision will be needful to glean greater insights and considerations for the development of population-based preventive health programmes and initiatives.