​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.

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About the Mental Health in Primary Care Programme

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. 

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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.

PCN GPs may contact their PCN headquarters and refer patients to PCN nurses for supportive counselling, which is covered under the PCN subvention. Patients with moderate needs can be referred to Community Intervention Teams (COMIT) for psychosocial interventions, such as psychotherapy, which are non-chargeable.


Support for Mental Health GP Partners

  • 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.