Community Mental Health Services and Aftercare (ASCAT)

Community Mental Health at SKH 

Sengkang General Hospital (SKH) provides comprehensive community-based mental health support through two key programmes under the Community Mental Health Masterplan developed by the Agency for Integrated Care (AIC), together with the Ministry of Health (MOH): 

• Assessment & Shared Care Team (ASCAT): The ASCAT programme supports the polyclinics, GPs, and community mental health partners with clinical consultation and capability building, while providing gatekeeping to hospital services. All cases with more urgent and severe mental health needs surfaced by community partners will be triaged by the ASCAT psychiatrist to determine if fast track service is required at the hospital.
• Aftercare: The Aftercare programme provides transitional care for clients who have mental health issues with complex medical and social needs, e.g. non-adherence to treatment and appointment, frequent relapse episodes, and facilitate their discharge, sustain their psychological well-being and re-integrate them back into the community. 

Launched in October 2023 at SKH, these programmes are hosted under the Department of Psychiatry and work together with partners in the community to ensure individuals with mental health needs receive timely care, coordinated support, and continuity as they recover in the community. 

Our Community Partners 

We work closely with AIC and a network of community mental health providers, including:

• Community Mental Health Teams (CMHT), such as Community Outreach Team (CREST) and Community Intervention Team (COMIT)
• Health and Wellness Clinics (HWC) at Polyclinics
• Mental Health General Practitioner Partners (MHGPPs)

Assessment & Shared Care Team (ASCAT)  

SKH ASCAT is a multi-disciplinary team of psychiatrists, psychologists, and medical social workers, working in tandem with Aftercare case managers. 

Who We Serve: 

• Adults aged 18 years and above 
• Residents primarily living in Sengkang, Punggol, and Seletar 
• Individuals experiencing moderate to severe mental health difficulties 

Conditions We Treat:

• Depression 
• Anxiety disorders 
• Bipolar disorder
• Obsessive-compulsive disorder (OCD) 
• Psychosis (selected cases) 
• Dementia with behavioural or psychological symptoms 

Please note that ASCAT does not currently provide services for ADHD, autism, eating disorders, addiction, antenatal, or forensic cases. Clients requiring these services will be referred to appropriate specialist providers. 

Our Commitment: Clients who meet our intake criteria receive their first appointment within 10 working days (excluding weekends and public holidays).  

How can ASCAT support the client? 

ASCAT collaborates with primary care and community mental health partners to provide support to clients through the following ways: 

• Develop capabilities of primary care and community mental health partners: ASCAT enhances the skills and knowledge of primary care and community mental health partners through training, case discussions, and clinical supervision to provide quality mental health care in managing clients with subclinical, mild to moderate mental health conditions. 
• Provide triaging and gatekeeping for more urgent and severe cases: ASCAT provides triaging for cases with more urgent and severe mental health needs surfaced by MHGP and COMIT to ensure that appropriate clients receive fast-tracked services for quick stabilization at the hospital. Upon stabilization, clients are right-sited back to the community for ongoing support from primary care and community mental health partners. 
• Co-manage severe or complex cases: ASCAT collaborates with community mental health partners to co-manage severe or complex cases, ensuring that clients receive comprehensive care. 
• Provide clinical leadership: ASCAT provides clinical leadership in developing an integrated community mental health ecosystem, fostering collaboration among various stakeholders to enhance the overall quality of mental health care in the community. 

Aftercare Programme 

SKH Aftercare case manager(s) work in tandem with ASCAT’s multi-disciplinary team of psychiatrists, psychologists, and medical social workers. 

Who We Serve: 

• Adults aged 18 years and above 
• Residents primarily living in Sengkang, Punggol, and Seletar 
• Individuals receiving care from SKH Psychiatry and Psychology services who have: 
  • Multiple or complex needs requiring community mental health provider support (including mental health, social, medical, or caregiving challenges)
  • A history of frequent relapses or hospital admissions 
  • Difficulty maintaining treatment adherence or attending follow-up appointments 

Our Impact: As of December 2025, the Aftercare Programme has reached out to 200 individuals.

How can Aftercare support the client? 

The Aftercare programme collaborates with community mental health partners to: 

• Ensure Continuity and Coordination of Care: Aftercare provides transitional care serving as the single point of contact for community mental health partners; this ensures the continuity and coordination of care when client transits between different care settings or levels of care.
• Support Clients’ Recovery: Aftercare supports clients’ recovery by conducting holistic needs assessment and providing appropriate resources. Clients are co-managed with community mental health partners during the transitional care period to address the psychosocial needs and follow-up care, fostering a more supportive recovery environment.
• Adopt a Co-Management Approach: Aftercare adopts a co-management approach for the targeted demographic through a shared structural framework to identify and monitor clients, along with defined escalation processes and protocols to address the needs of this group.
• Facilitate Information Flow: A key aspect of Aftercare is the facilitation of information flow. This includes sharing care plans with community mental health partners within the mental health ecosystem, ensuring that all parties are informed and aligned in their efforts to support clients.

Community Mental Health Support Resources 

• Support in the Community: Find out more about Community Mental Health Programmes 
• Support in the COmmunity for Youth: Visit realspace.sg for credible mental health resources and real solutions to encourage help-seeking behaviors.
• First Stop for Mental Health (FSMH) - CLICK, CALL, VISIT: 

First Stop for Mental Health If you are unsure about the type of mental health support you need, you can click, call or visit care professionals from the First Stop for Mental Health. These trained care professionals will help identify your mental health needs, provide tailored support and guide you to the most suitable services.
CALL national mindline 1771 or WhatsApp 6669 1771 to talk to someone	CLICK mindline.sg for self-help resources	VISIT community mental health teams such as CREST or connect with CHAT

Photo Gallery

_{Left to Right: AIC Community Mental Health Masterplan Coffee Book, ASCAT and Aftercare team at SKH’s Community Mental Health Fair 2024, Core Module Training.}