Mental Health General Practitioner Partners
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Chronic Disease Management Programme (CDMP)
Community Health Assist Scheme (CHAS)
Mental Health General Practitioner Partners
Primary Care Networks (PCN)
Public Health Preparedness Clinic (PHPC)
Screen For Life (SFL)
Vaccination and Childhood Developmental Screening Subsidies (VCDSS)
Singapore National Asthma Programme (SNAP)
Antimicrobial Utilisation Surveillance Initiative

​About the Community Mental Health Masterplan

Since 2012, the Agency for Integrated Care (AIC) has been appointed by the Ministry of Health (MOH) to develop the Community Mental Health (CMH) Masterplan. The plan focuses on working closely with the health, social and community care partners to build an integrated mental health network to better support for persons at risk/with mental health issues including dementia and their caregivers in the community.

Building a Well-Connected Community Mental Health System to Support Residents Needs.png



Mental Health in Primary Care is one of the programmes under the CMH Masterplan developed by AIC, together with MOH, which enables persons living with mental health issues and/or dementia to seek early treatment nearer to their homes and ensure that they are well-supported in the community.

Clients with mild to moderate mental health and chronic health conditions can seek holistic treatment at a nearby General Practitioner (GP) clinic or Polyclinics. The programme enables individuals to seek consultation, diagnosis and treatment close to home in a less stigmatising environment. 


Tiered Care Model for the Community Mental Health Ecosystem.png

About the Mental Health General Practitioner Partnership (MH GPP)

As a Mental Health GP Partner, you will provide care to patients with mild to moderate mental health and chronic health conditions through:

  • Consultation, diagnosis, pharmacotherapy, and treatment to support the patient in coping and improving daily functioning

  • Education and resources for caregivers on how to better engage and support their loved ones, and link them up with appropriate resources

  • Adopting a team-based approach involving medical and allied health services to provide comprehensive support

About the Primary Care Network – Mental Health (PCN-MH) Initiative

Building on the efforts to strengthen mental health support in the community and primary care, AIC worked with Primary Care Networks (PCNs) to develop the PCN-MH Initiative. PCN-MH complements the existing MH GP partnership by offering team-based and holistic care and support for patients with mental health and chronic conditions.

To complement the medical care provided by GPs to mental health patients, referrals to Community Intervention Teams (COMITs)​ or PCN nurses1 are also made accessible and affordable. PCN GPs may contact their PCN headquarters and refer patients to PCN nurses for supportive counselling, which is covered under the PCN funding.

 
1Referrals to PCN nurses for mental health counselling are only applicable for PCN GPs.​​



Benefits of Co-Managing Chronic and Mental Health Conditions in the Community

  • Holistic and Integrated Care

    • Patients can receive care for their chronic and mental health conditions from a nearby GP clinic that is familiar to them.

    • PCN Nurses are trained to:

        • Administer simple tools to detect mental health needs during the regular chronic nurse counselling sessions.

        • Provide supportive counselling for patients with mild mental health conditions, draw up personalised care plans for chronic and mental illness, and provide education to empower patients to self-manage their condition(s) holistically.​

  • Health and Social Coordination

    • The Community Intervention Team (COMIT)​ is an allied health-led team which supports patients in their mental health needs and connect them to relevant community resources and services.

      ​What are Community Intervention Teams (COMIT)?

      The Community Intervention Teams (COMITs) provide assessment, counselling, psychotherapy, case management and psychoeducation support to patients with mental health issues and dementia, as well as their caregivers. These services are fully funded by the government and are provided free-of-charge to patients.       ​

    • AIC has paired each GP clinic to a COMIT provider, to facilitate GPs' identification of a community mental health partner who can supplement the psychosocial interventions. Regardless of the pairing, you are not restricted to refer to only your partner COMIT. Should you or your patient have a preferred/existing working relationship with another COMIT provider, you have the choice to refer as desired after discussing with your patient. 

    • You may refer patients with mild-moderate mental health conditions to your paired COMIT provider directly without going through AIC CareinMind (CIM). You may refer to COMIT by writing a hard-copy memo for the patient to walk-in to the COMIT. The memo should minimally contain information, such as:

      • Patient's name and NRIC

      • Presenting condition

      • Other information deemed appropriate, e.g. medication started

    • Alternatively, you may also refer to COMIT by completing the referral form and emailing to your paired COMIT provider directly or through AIC CIM (careinmind@aic.sg) to facilitate the referral. 

    • With the support available across our network of partners, the management of patients' mental health conditions can be successfully anchored in the community and facilitated by health-social integration.


  • Capability Building

    • As a Mental Health GP partner, you will have access to Continuing Medical Education (CME) talks and case discussion platforms that are regularly organised by the Assessment and Shared Care Teams (ASCATs). These trainings provide opportunities to enhance your competencies in the latest treatment modalities of mental healthcare.

      What are Assessment & Shared Care Teams (ASCAT)?

      Each Assessment & Shared Care Team (ASCAT) comprises multi-disciplinary healthcare professionals to provide assessment, treatment, and holistic care for patients with severe mental health conditions. In addition to supporting patients and caregivers, the team also enhances the mental healthcare capability of GPs through training and clinical co-consultation.

  • Affordable Care for Patients

    • In addition to participating in Community Health Assist Scheme (CHAS) and Chronic Disease Management Programme (CDMP), your clinic could participate in MH GPP to register as a Chronic Disease Management Programme - Mental Illnesses (CDMP-MI) accredited clinic, also known as CDMP+, allowing patient to tap on MediSave claims. CDMP complements CHAS subsidies, allowing eligible patients to tap on Medisave to claim for outpatient treatment of the chronic condition to defray the costs of the treatment.

  • Drug Support

    • Mental Health GP Partners will be granted access to lower cost psychiatric drugs​​

    • Available drugs are limited to a stipulated drug listing which will be updated and disseminated monthly to your registered email

    • Participating GPs may procure the listed psychiatric drugs from AIC's appointed vendor and pass on the cost savings to their clients with mental health needs

    • Orders can be sent via fax to the pharmacy @ 6385 0802 or emailed to order_psc@pharmacy.nhg.com.sg. You may use this drug order form.

  • Direct access for clients requiring higher level of care needs through ASCAT

    • Patients with moderate to severe mental health symptom(s) may be referred to ASCAT teams in Public Hospitals for further intervention and stabilisation before they are right-sited back to the community.

    • Each GP partner enrolled in Mental Health General Practitioner Partnership (MH GPP) and/or Primary Care Network – Mental Health (PCN-MH) is partnered with an ASCAT programme, for support and capability training.

    • You may contact the ASCAT teams that you are partnered with if you have any questions regarding the care of your mental health patients such as changing of medications and escalation of the patient's case to hospitals.​


Please refer to the diagram below for more information on the onboarding process for the Mental Health GP Partners Programme:


GPs must be part of a Primary Care Network (PCN) in order to participate in the PCN-MH programme.  If you are currently not part of a PCN and would like to join one, please feel free to reach out to your AIC account manager for more information.

If you are keen to participate in the MH GPP/PCN-MH initiative, kindly complete this partnership form and submit it to your PCN HQ or AIC Account Manager.​
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Criteria for CDMP-MI Accreditation (According to the CDMP Handbook for Healthcare Professionals 2022​) 

Only doctors and clinics/medical institutions which are accredited for MediSave use and participating in the CDMP can make MediSave claims for patients. To make claims for Mental Illnesses1 (i.e. Schizophrenia, Major Depression, Bipolar Disorder and Anxiety), GPs additionally need to participate in the Mental Health GP Partnership Programme (MHGPP) and attend the CDMP-MI training provided under MHGPP​2. Doctors who are registered specialists in psychiatry do not need to join MHGPP and are exempted from CDMP-MI training. GPs are exempted from having to attend CDMP-MI training (but are still required to take part in MHGPP) if they have the following qualifications/background: 

  • Doctors with MMed (FM), GDFM or on the Register of Family Physicians, if the mental health training modules of these programmes include all the conditions in CDMP Mental Illnesses. 

  • Doctors with Family Medicine (FM) training who had 3-month postings at psychiatric departments at the any of the Public Hospitals from May 2007; 

  • Doctors who had 6-month postings at psychiatric departments at the various Public Hospitals from May 2007; OR 

  • Holders of the Graduate Diploma in Mental Health.  


1 Dementia is not considered a mental illness under the CDMP as of 1 January 2014. Physicians who wish to manage Dementia under CDMP are not required to participate in the MHGPP. 

2 The MHGPP is meant to provide specialised support (e.g. from psychiatrists and mental health trained nurses, as well as supply of drugs for mental illness) to primary care doctors and ensure that they have sufficient training and confidence in treating patients with mental health conditions.

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To better support care professionals in diagnosing and managing patients with mental health needs in the primary care setting, AIC has developed the following suite of resources for GP partners:

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AIC has developed an extensive range of resources that are available to the public to learn more about mental health, dementia, and caregiving. Please feel free to refer your patients and/or their caregivers to any of the following resources:

  • ​PCN-MH Service brochure​ which highlights the services provided under the PCN-MH programme. Do note that as of 1st July 2024, the ccmh@aic.sg email is no longer in use.  Please email enquiries@aic.sg or contact your AIC account manager​ if you have any questions or if you require more information.

  • Mind Matters Community Mental Health Resource Directory in English and Chinese which provides information on the mental health resources and services available in the community.

  • Mindline​ a digital mental health platform offering resources and support for emotional well-being and mental wellness in Singapore.

  • MindSG​ a platform for learning about self-care and to identify avenues for mental health support.

  • Community Mental Health Wayfinding Tool which allows individuals to find mental health services based on their needs, age and location.

  • Top 5 Mental Health Resources​ with information and tips to support caregivers in caring for themselves and their loved ones.

  • Mental Health Resources to Support Clients and Caregivers​ a consolidated list of mental health resources for clients and caregivers.