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)
Healthier SG Screening
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​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 of or living 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 a CMH Masterplan developed by AIC and MOH. It 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.

Patients 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. 


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About the Mental Health General Practitioner Partnership (MH GPP)

The Mental Health General Practitioner Partnership (MHGPP) is one of the initiatives under the CMH Masterplan, where GPs play a key role in enabling early identification and improving access to mental health services.

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

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

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

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

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To complement the medical care provided by GPs to mental health patients, refe​rrals 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.​You may contact your PCN headquarters for a referral to PCN nurses if needed.​​


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 who can support GPs to address the psycho-social aspects contributing to the mental health issues and provide case management for patients with complex needs. ​

​What are Community Intervention Teams (COMIT)?

The Community Intervention Teams (COMITs) provide comprehensive support through assessment, psychotherapy, psychosocial interventions such as cognitive behavioural therapy and psychoeducation support for patients aged 18 years and above with mental health condition 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 with a COMIT provider to facilitate GPs to identify a community mental health partner who can supplement the psychosocial interventions. However, these pairings are not restrictive. If you or your patient prefers another COMIT or community provider, you may refer to that provider after discussing the choice with your patient. 

  • You may wish to check with your PCN if there are resources to support you in referring to COMIT, such as your PCN nurses or PCN HQ.

  • To refer patients with mild-moderate mental health conditions to your paired COMIT provider, simply prepare a memo for your patient to bring to the COMIT. The memo should include at minimum the following information: 

    • ​​Patient's name, NRIC and contact number

    • Presenting symptoms/ issues

    • Reason for referral

    • Patient’s psychotropic medications started, if any

    • Clinic contact details

Alternatively, if you are concerned that a patient may not comply with COMIT follow-up, you may email the patient's details to your paired COMIT to initiate the referral. 

If you are familiar with referring via AIC CareinMind  (careinmind@aic.sg) and prefer this method, this route will remain available.​

With the existing network of partner support, patients' mental health care can be anchored in the community and strengthened through integrated social and healthcare services.​​


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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), to enhance your competencies in managing mental health cases and understanding the latest treatment modalities.

  • Each Assessment & Shared Care Team (ASCAT) is a psychiatrist-led, multi-disciplinary team set up within each Regional Health System (RHS) cluster to build capability of the GPs, polyclinics and community mental health partners, through clinical consultation and capability building to enable them to manage patients with mild to moderate mental health conditions in the community.

What are Assessment & Shared Care Teams (ASCAT)?

Direct access for patients with severe or complex care needs​

  • ​Cases identified by Mental Health GP partners as urgent or severe will be triaged by the ASCAT team to determine whether fast-track hospital services are required. Upon stabilisation, ASCAT will right-site clients back to the GP, to be supported by primary and/or community mental health partners.

  • ​​​​​​Contact your partnered ASCAT, if you have any questions regarding the care of your mental health patients such as changing of medications, co-consultations, case discussions, co-management for complex cases, or referral of patients with urgent care needs to hospitals. 

  • All Mental Health GP partners are partnered with an ASCAT upon MHGPP onboarding. Please write in to mhgpp@aic.sg should you wish to find out which ASCAT you are partnered with. ​

Affordable Care for Patients

  • In addition to participating in Community Health Assist Scheme (CHAS) and Chronic Disease Management Programme (CDMP), your clinic can participate in MH GPP to be accredited as a Chronic Disease Management Programme - Mental Illnesses (CDMP-MI) or CDMP+ clinic. This accreditation complements CHAS subsidies, allowing eligible patients to tap on Medisave and defray the cost of outpatient treatment of chronic mental health conditions including major depression, anxiety, bipolar disorder, and schizophrenia.

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 and pass on the cost savings to your patients with mental health needs


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


    If you are keen to participate in the MHGPP, please contact your AIC account manager for more information or submit this partnership form​ to your PCN HQ.

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    Criteria for for onboarding the Mental Health GP Partnership

    From 1 January 2026, only GPs who meet the below criteria are eligible to onboard MHGPP, upon application approval by AIC:

    1. New entrant doctors with either (i) MMed(Family Medicine) (MMed (FM)) or (ii) Graduate Diploma in Mental Health (GDMH); and 

    2. ​New entrant doctors must be working in a clinic which has onboarded the HSG scheme

    When the new criteria takes effect on 1 January 2026, GPs who are already on MHGPP may continue with the partnership even if they do not possess MMed(FM) or GDMH. ​

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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 a suite of resources for you:

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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:

    • 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.

    • Real is a safe space for youth to be connected to mental health support and access targeted resources.

    • 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.