RC-IMH Integrated Social Health Team

In partnership with the Institute of Mental Health (IMH), the team pioneered a model that bridges community and medical settings, addressing long-standing gaps in information-sharing, assessment processes, and caregiver support.

The pilot served clients accessing services from both organisations, with a multidisciplinary team of psychologists, social workers, and a medical social worker working jointly to streamline care. Key outcomes included a single point-of-contact case worker, joint intervention sessions, and a caregiver toolkit for navigating IMH services. These innovations helped improve access, reduce duplication, and build trust among professionals and caregivers alike.

To support implementation, the team developed new tools—including a 20-item Complexity Measure—to guide shared assessments and deepen collaboration. They overcame logistical barriers to trial community interventions within hospital grounds, and gradually expanded access to therapy rooms through sustained trust-building. The approach strengthened confidence in managing care across settings while helping to reduce treatment delays and avoid premature institutionalisation.

The ISH model has led to lasting sector impact. At the pilot’s conclusion, 9 of 11 clients showed measurable reductions in complexity and support needs. Learnings from the initiative have informed the sector-wide Disability Case Management Programme Plus (DCMP-Plus), which will scale integrated case management to serve up to 75 clients across all settings. The pilot’s tools, frameworks, and workforce recommendations have since guided new programme development.

The team’s work continues to enhance cross-agency communication, improve discharge outcomes, and inform person-centred care practices for individuals with complex needs. For their innovation, perseverance, and sustainable impact on care integration, RC-IMH Integrated Social Health Team is awarded the Team Award 2025.

Team members include:

1. Lee Xing Ru Cynthia, Senior Assistant Director, Allied Professional Services

2. Huang Jingda Ryan, Senior Psychologist

3. Charlene Tan, Senior Medical Social Worker