Family medicine for healthy ageing in the heartlands
As we grow older, most people do not have just one medical condition. Instead, seniors often live with a mix of long-term illnesses, medications, mobility issues, memory changes, sleep problems and social stresses. These interact with one another and with the home environment, making care more complex than simply treating each disease in isolation.
At Kenneth Tan Medical Clinic, we provide continuity of care for older adults in the heartlands. We look after seniors who live in the neighbourhoods around our clinics, so that care is accessible, familiar and close to home. Our focus is not only on test results, but on what matters most to each person: staying safe, steady, comfortable and connected for as long as possible.
A family medicine approach, not just organ-by-organ care
Specialists such as cardiologists, nephrologists, neurologists and orthopaedic surgeons each focus on one part of the body. Their input is important when specific tests or procedures are needed. However, many older adults end up seeing several specialists at once, each with their own medications, follow-up plans and priorities. This can be confusing and tiring, and sometimes results in long trips to hospitals or large centres far from home.
Family Physicians work differently. We:
- Look at the whole person – medical conditions, function, mood, thinking, home situation and caregivers.
- Pay special attention to the classic “geriatric giants” – problems such as falls and unsteadiness, immobility, incontinence, memory and thinking changes, depression, frailty and medication side effects, which often matter more to seniors than individual lab numbers.
- Coordinate care across multiple conditions and clinics, helping to make sense of different specialist recommendations and medication lists.
- Build a long-term relationship with the senior and family, so that decisions can be made in line with their values and changing goals over time.
Having a single main doctor who understands the full picture can reduce duplication, conflicting advice and avoidable side effects, and can make it easier for families to know whom to turn to when something changes.
Care in your neighbourhood, not just in central hospitals
Our clinics are located within residential estates, close to where seniors live, shop and meet friends. For many older adults, especially those with reduced mobility or who rely on family members for transport, travelling repeatedly to a distant hospital or large polyclinic can be exhausting.
Receiving most care in a heartland family practice offers several advantages:
- Shorter travel distances and waiting times, which means less fatigue and disruption to daily routines.
- A familiar environment, where reception staff and nurses recognise the senior and understand their preferences.
- The ability to combine several needs in one visit – for example, reviewing blood pressure and diabetes, assessing falls risk, renewing a driving licence and updating vaccinations – instead of having to attend multiple clinics.
When hospital care or specialist review is truly required, we will still arrange it and provide a clear referral. But our aim is to anchor the majority of day-to-day care close to home, where it is most sustainable.
Working within Healthier SG and the Primary Care Network (PCN)
Our clinic participates in national initiatives such as Healthier SG and the Primary Care Network (PCN), which are designed to strengthen primary care and support older adults to age well in the community.
Under Healthier SG, residents enrol with a regular family doctor and develop personalised health plans, with an emphasis on preventive care, chronic disease control and community-based support.
Through the PCN, GP clinics work together in a network, supported by nurse counsellors and care coordinators. This team-based model allows patients with chronic conditions such as diabetes, high blood pressure and high cholesterol to receive structured care, including nurse education, diabetic retinal photography, diabetic foot screening and regular tracking of key indicators.
For older patients who are struggling with medical, functional or social issues, we can also tap on PCN and community resources to link them to:
- Home nursing or therapy services where appropriate
- Day care and activity centres
- Social workers, financial assistance and caregiver support services
This means our role goes beyond writing prescriptions; we help connect seniors and families to the wider support network around them.
What we do for older adults
In practice, our elderly care covers a wide range of needs, including:
- Chronic disease management – ongoing care for conditions such as diabetes, high blood pressure, high cholesterol, heart disease, stroke, chronic lung disease, kidney problems, thyroid disease and arthritis. We aim to align with national care pathways while tailoring plans to each senior’s frailty level, life expectancy and personal goals.
- Medication review and simplification – checking that all medications remain necessary, safe and appropriate for age and kidney function, looking out for drug interactions and side effects, and exploring opportunities to deprescribe where sensible.
- Falls and balance assessment – asking about previous falls, reviewing gait and balance, checking vision, footwear and home hazards, and addressing factors such as blood pressure, dizziness and muscle strength that can increase the risk of falls.
- Frailty and functional assessment – taking note of weight loss, weakness, slowness, exhaustion and changes in daily activities, and planning interventions such as exercise, nutrition and support services to slow decline where possible.
- Memory and mood – screening for dementia, mild cognitive impairment, depression and anxiety, and supporting both the senior and caregivers in understanding and adapting to changes.
- Sleep and continence – addressing insomnia, daytime sleepiness, urinary frequency, incontinence and related issues that significantly affect quality of life.
- Preventive care and vaccinations – reviewing screening for conditions such as osteoporosis and certain cancers where appropriate, and keeping up to date with recommended vaccinations for older adults.
- Driving licence medical assessments – conducting medical reviews for driving licence renewal, discussing fitness to drive and safety, and where necessary, working together with the senior and family to make thoughtful, respectful decisions about stopping or modifying driving.
Planning ahead: AMD and Lasting Power of Attorney (LPA)
Good elderly care is not only about today’s symptoms; it is also about planning ahead for future decisions.
In our clinic, we support seniors and families with Advance Medical Directives (AMD) and Lasting Power of Attorney (LPA) applications:
- For AMD, we can explain what the directive means in practical terms, discuss common questions, and carry out the medical examination and witnessing required as part of the statutory process, if you decide that making an AMD is right for you.
- For LPA, we can help review relevant medical information and, where appropriate, provide the medical assessment needed to support the appointment of donees, especially when there are questions about mental capacity or existing health conditions. We also encourage families to think through how the LPA should work in real life, so that appointed decision-makers are prepared when the time comes.
We currently do not conduct formal Advance Care Planning (ACP) sessions in the clinic. However, we are happy to talk about your values and wishes for future care in the context of your medical consultations, and to point you towards ACP resources or services if you wish to explore this more formally.
These conversations are often easier when there is already a relationship of trust with a regular Family Physician. Our goal is to create a safe space where seniors and families can discuss difficult topics early, at their own pace, before a crisis occurs.
The benefit of one main doctor for many conditions
When a senior has multiple illnesses and sees several specialists, it can be hard to know who is “in charge”. In a family medicine model, your Family Physician is the anchor doctor who:
- Keeps an updated overall medication list and problem list
- Helps weigh up trade-offs, for example between aggressive disease control and side effects or dizziness that might increase falls
- Coordinates timing and purpose of specialist visits, so that each visit adds value rather than repeating the same tests
- Has ongoing conversations with the senior and family about goals of care – whether the priority is longevity, comfort, staying at home, or avoiding hospitalisation
This does not replace specialist care when it is needed, but it helps ensure that all care is pulling in the same direction, aligned with what the senior actually wants.
What to expect during an elderly care visit
An elderly care consultation usually starts with a careful review of the current situation. We will ask about your medical history, medications, recent hospital or specialist visits, and any new symptoms or concerns. We pay particular attention to falls, changes in walking, memory or mood, weight loss, appetite, continence, sleep and ability to manage daily tasks.
We then perform a focused examination, which may include blood pressure (sometimes measured both sitting and standing), heart and lungs, joints and mobility, neurological signs and vision. If appropriate, we may use simple, validated tools to screen for frailty, cognitive change or depression, and arrange relevant blood tests or other investigations.
After this, we discuss our impressions and agree on a plan. This may involve adjusting medications, scheduling follow-ups for chronic conditions, arranging further tests, suggesting exercises or therapies, linking you with community services, or setting aside a future visit to discuss AMD or LPA in more detail if you wish. We welcome family members or caregivers to attend, if the senior is comfortable with this, so that everyone understands the plan and can support it at home.
Supporting seniors and caregivers over time
Ageing is a journey, not a single event. Needs and priorities change over the years, especially after events such as a fall, hospital admission or new diagnosis. Our role is to walk alongside seniors and their families through these transitions, helping to anticipate problems where possible and respond early when they arise.
If you or your loved one would like a comprehensive review of health, function and medications, are concerned about recent falls, memory changes or increasing frailty, or are thinking about AMD or LPA, we would be glad to see you.
You can book an appointment online or call us to speak with our staff.
If possible, bring along a list of current medications (or the actual medication packets), recent clinic or hospital letters, and information about any community services already involved, so that we can build on what has already been done and coordinate care effectively.