Mental Health General Practitioner Partners
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Chronic Disease Management Programme (CDMP)
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Mental Health General Practitioner Partners
Primary Care Networks (PCN)
Public Health Preparedness Clinic (PHPC)
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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/with mental health issues including dementia and their caregivers in the community.

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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.

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 Community Mental Health 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, 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.​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 to a COMIT provider, to facilitate GPs' identification of a community mental health partner who can supplement the psychosocial interventions. Note: 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 can now refer patients with mild-moderate mental health conditions to your paired COMIT provider directly 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, you may also consider emailing the patient details to your paired COMIT directly for the referral, for patients whom you may have concerns with compliance to follow up at COMIT. 

      • 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 support across partners, the care of patients’ mental health condition can be anchored in the community and facilitated by social-health integration.​

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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.

      What are Assessment & Shared Care Teams (ASCAT)?

      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.

  • Direct access for patients with severe or complex care needs​

    • ​ All cases with more urgent and severe mental health needs surfaced by MH GP partners will be triaged by the ASCAT team to determine if fast track service is required at the hospital. 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. 

    • If you are a Mental Health GP partner, you would be partnered with an ASCAT upon your 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 could participate in MH GPP to register as a Chronic Disease Management Programme - Mental Illnesses (CDMP-MI) accredited clinic, also known as CDMP+, allowing eligible patients to tap on MediSave claims for conditions including Major Depression, Anxiety, Bipolar Disorder and Schizophrenia. 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 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 not currently not enrolled in MHGPP, please feel free to reach out to your AIC account manager for more information.

    If you are keen to participate in the MH GPP, kindly complete this partnership form and submit it 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 you may 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.