Community resources are limited. Most are run by Voluntary Welfare Organisations that depend on subsidies from the government and funds raised from donations and activities. The out-of-pocket payment from patients depends on per capita household means testing. Patients are matched to the type of services based on their functional statuses. The tools used for functional assessments are the RAF forms and Modified Bartel Index. Applications for most of the community services are done online through the Agency of Integrated Care. Essentially, there are three types of community resources, namely financial, psychosocial, and care resources to help patients in need. To navigate this social maze, Family Physicians will need to familiarise themselves with the type of resources available, the means testing procedure, as well as the referral system. After assessing the patient’s needs and functional status, family physicians will have to match the services that can best serve their patient’s needs.

Singapore has a rapidly ageing population with an increasingly complex chronic disease burden. The number of seniors living alone has also tripled in the last 15 years. Primary care physicians will have to change the way that we delivery primary care. Patients have multi-comorbidities and are sicker. Family Physician Practice has to enhance the coordination of medical and social care and the provision of comprehensive care across the entire cycle of care. This can be achieved by being connected to the health system and resources, making additional efforts in providing care coordination to navigate the health system, and optimising clinical social care around the patient’s needs with a multi-disciplinary team (MDT). There has been an increase in the number of services in the community but gaps still exist, especially in the coordination of healthcare and psychosocial care services. The team will need to tap on all available services to ensure patients’ medical and social needs are taken care of and they are enabled to age gracefully in place.