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’s (AIC), together with the Ministry of Health (MOH): 

• Assessment & Shared Care Team (ASCAT): The programme aims to enhance the capability of primary care and community partners to provide quality mental health care and develop an integrated community mental health ecosystem. 
• Aftercare: The programme aims to integrate health and social care through collaborative partnership by providing holistic needs assessment and management in collaboration with identified health and social care partners. 

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 Intervention Team (COMIT) and Community Outreach Team (CREST), Health and Wellness Clinics (HWC) at Polyclinics, and Mental Health General Practitioner Partners (MHGPPs) to deliver integrated care across the community.  

Assessment & Shared Care Team (ASCAT)  

The Assessment & Shared Care Team (ASCAT) comprises a multi-disciplinary team, set up within each Regional Health System (RHS) clusters to support the polyclinics, GPs, and community mental health partners (CMHPs) with clinical consultation and capability building to enable them to manage clients with mild to moderate mental health issues in the community. 

ASCAT will provide gatekeeping to hospital services. All cases with more urgent and severe mental health needs surfaced by MHGPPs and COMIT will be triaged by the ASCAT psychiatrist to determine if Fast-Track service is required at the hospital. Upon stabilisation, ASCAT will right-site clients back to the community to be supported by primary care and/or community mental health partners. 

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

Clinical Care Services 

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).  

Capability Building 

Beyond supporting clients and caregivers, ASCAT strengthens the broader community mental health ecosystem by building the capabilities of primary care and community mental health partners through comprehensive training and clinical leadership programmes. 

Training Programmes Delivered 

• Preceptorship Programme: 100 weekly sessions delivered, providing hands-on mentorship to primary care professionals. 
• Case Discussion Forums: 47 weekly sessions delivered, with over 50 cases discussed collaboratively. 
• Educational Training: Core Module Training reached 295 CMHPs across 10 sessions, whilst Mental Health GP Talks engaged 113 general practitioners (GPs) over 4 sessions. 
• Skills Development: Mental State Examination workshop has the potential to train up to 120 CMHPs over 10 sessions per year. The Clinical Observership Programme provides intensive learning opportunities for up to 20 CMHPs over 10 sessions per year.  
• Future Development: The team continues to expand its educational offerings, actively developing new curriculum modules to address emerging training needs within the community mental health workforce. 

Aftercare Programme 

The Aftercare team provides transitional care support for clients who have mental health issues with complex medical and social needs. Hospitals are resourced with case manager(s) to support clients and link them to CMHPs for co-management of health and psychosocial needs or longer-term interventions and monitoring. The case manager(s) also act as the point of contact for CMHPs to discuss and collaborate on care plans for clients with deteriorated conditions. 

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 244 individuals and provided active case management services to 122 clients. 

_{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.} 

Community Mental Health Support Resources 

• Support in the Community: Find out more about Community Mental Health Programmes 
• Explore Online Resources: Visit Mindline for mental health information and support 
• Find Local In-person Support: Use the CMH Wayfinding Tool to locate your nearest Mental Health Team 
• 24/7 Support: Call 1771 or WhatsApp Text 9669 1771 to talk to a mental health counsellor anytime