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The investigators will provide an integrated community of care to a socioeconomically disadvantaged population. This included an extended cycle of care from tertiary care to primary care and linkages with social care agencies in the community.

Socioeconomically disadvantaged patients are at higher risk of unplanned readmissions, ill health from higher chronic disease burden and utilize more healthcare resources. In Singapore, people at the lowest strata of socioeconomic status have an 8 times higher risk of inpatient utilization and twice the risk of having multiple chronic diseases, while utilizing less primary care compared to the general population. The reasons for poorer health outcomes are many, including lack of social support, and a subsidy system that encourages acute hospital utilization instead of primary care utilization. A community-based intervention program that extends into the rubric of these communities is required to address the social determinants of poor health, and break the intractable cycle of low socioeconomic status and poor health. The investigators will develop an integrated community of care comprising of integrated practice units (IPUs) such as the Integrated Clinical Care Service, Transitional Home Care from Singapore General Hospital, Care Closer to Home Program from the Agency of Integrated Care, Chinatown Point Family Medicine Clinic and Ageing gracefully at home from the grassroots to systematically deliver primary, transitional and social care to a socioeconomically disadvantaged population at the Chin Swee and Banda residential estate. A community-based integrated care team will support and connect the various IPUs in the form of a community virtual ward. Residents enrolled into the intervention program will be followed up prospectively for one year. The effectiveness of an integrated community of care in improving health outcomes will be evaluated and the investigators hypothesize that the program will be cost-effective in improving the health status of socioeconomically disadvantaged populations in Singapore. The results of the study will be informative to policy makers to deliver value based healthcare and acts as a blueprint for other regional health systems to deliver care to similar populations.

Inclusion Criteria:

1. Residents > 60 years old

2. Staying in 1 or 2 room rental flats in the Block 51 and 52 Chin Swee and Block 5 Banda Street residential estate

3. Have at least 1 episode of the following:

   1. SGH Specialist outpatient clinic attendance
   2. SGH A&E attendance
   3. SGH Inpatient stay

Exclusion Criteria:

1. Patient declines service
2. Patient has aggressive / abusive behaviour