Community Case Management Service (CCMS)

About Community Case Management Service (CCMS)


LB’s Community Case Management Service provides support for vulnerable seniors* and their caregivers who face difficulties in managing their multiple health and social care needs, so that they may continue living in the community or at home as long as possible.

We deliver holistic care centred on the individual’s needs, thus empowering the seniors in managing their own care independently or with the help of their families / caregivers / community services, and optimising their health and quality of life in order to promote ageing-in-place.

* A vulnerable senior is a person who suffers from social isolation, depression or physical disabilities, which leads one to be unable to care for oneself.

Programme Objectives

  • Prevent or delay institutionalisation of vulnerable seniors by delivering holistic care centred on an individual’s needs.
  • Empower the seniors in managing their own care independently or with the help of their families / caregivers / community services.
  • Optimise seniors’ health and quality of life and to promote ageing-in-place.

Profile & eligibility criteria

  • 60 years & above

         A) Meet at least 2 items from Domain A below:

  • No caregiver, or caregiver issues (e.g. caregiver unable to cope);
  • Family or domestic issues (e.g. neglect);
  • Social isolation or low mood (e.g. withdrawal from interest and family);
  • Require review on environmental safety or unstable housing arrangement (e.g. cluttering); or

        B) Meet 1 item from  Domain A and the below item from                        Domain B:

  • Poorly controlled chronic condition(s)1 or advanced disease(s)2, which requires assistance and monitoring; or

       C) Meet 1 item from Domain A and the below item from                         Domain C:

  • Physical, mental or cognitive impairment affecting Activities of Daily Living (ADL)** and /or Instrumental Activities of Daily Living (IADL)*** or behaviour, which require coordination of services to remain in the community.

Residents below 60 years old would be considered on a case-by-case basis.

1 “Poorly controlled chronic condition(s)” refers to chronic disease(s) that has (have) not met acceptable treatment targets which resulted in active symptoms affecting the well-being or general condition of the person; or that may result in long term complications.

2 “Advanced disease(s)” refers to disease(s) at later phases of the disease trajectory whereby typically there is a high symptom burden, functional loss and/or poor prognosis.

** The six activities of daily living (ADL) set by the Ministry of Health are mobility, feeding, transferring, dressing, bathing and toileting.

*** IADL includes the six daily tasks: Housekeeping, Meal Preparation, Medication Intake, Shopping, Use of Telephone and Money Management.


Refer a Senior

If you know of seniors who meet the above criteria and lives in the following districts, you can help by referring them to us.

Click on the CCMS Referral Form button to download the form and send the completed form via email to the respective office, and cc AIC (

Be A CAN Carer