This article shows how Primary Care Physicians can manage stable chronic schizophrenia with complex psycho-social issues in the community. This is made possible through improved access to mental healthcare services. The case study highlights the utilisation of the Mental Health-GP Partnership Programme and Community Mental Health Team to facilitate a smooth transition and maintenance of mental well-being in the community. Resources like Aged Psychiatry Community Assessment and Treatment Service, Assessment and Shared Care Teams, Community Intervention Teams are discussed as well as future directions to strengthen care in the community.

Singapore is among the fastest-aging countries in the world. By 2030, about one in every five residents would be 65 years or older and many of them may need long-term home care. Local studies have predicted a rise in disability rates as the population ages. To meet this need, our government has ramped up home care services to enable the elderly to “age in place” at home. In line with the Singapore Ministry of Health's vision of building sustainable healthcare and the initiative of "Beyond Hospital to Home", transitional care programmes in hospitals were renamed Hospital-to-Home in April 2017.

Patients who require a stay in a community hospital usually tend to be more complex, presenting not only with biomedical issues with complications, but also with a myriad of psychological and social issues as well. If they were to be discharged from an acute hospital directly to primary care and community, the patients and caregivers may feel helpless, overwhelmed and unsure of how to navigate the healthcare system to get their complex issues sorted out. Family physicians in the community hospitals need to hone their skills in such an area of care. The SBAR4 model can be effectively used to categorise the patients’ multiple bio-psycho-social issues, coordinate the multi-disciplinary team to bring hospital and community resources to help such patients, provide holistic care for such patients, and transit them safely into the care of our family physicians in primary care and community.